Epidemiological differences between adenocarcinoma of the oesophagus and adenocarcinoma of the gastric cardia in the USA

BACKGROUND AND AIMS

It has been suggested that gastric cardia adenocarcinoma (GCA) is a distinct entity from oesophageal adenocarcinoma (OA). We examined several epidemiological features of GCA and OA in the USA to elucidate differences/similarities between these malignancies.

METHODS

Using the database of Surveillance, Epidemiology, and End Results (SEER) program, we examined incidence rates for temporal changes, and ethnic and age distributions, and performed birth cohort analyses for cases with morphologically and histologically confirmed OA or GCA.

RESULTS

The age adjusted incidence rates of OA rose progressively, reaching 1.8 per 100 000 (95% confidence interval 1.7-1.9) during 1987-1991 and 2.5 per 100 000 (2.3-2.6) during 1992-1996. In 1992-1996, Whites were affected five times more than Blacks, and men eight times more than women. A significant increase in incidence occurred among younger persons aged 45-65 years. Irrespective of age, OA was characterised by higher incidence rates among more recent birth cohorts: a 40% increase in incidence for each five year increase in the date of birth--a "birth cohort effect". On the other hand, the incidence rates of GCA reached their highest level of 3.3 per 100 000 (3.2-3.4) in 1987-1991 and subsequently declined during 1992-1996 to 3.1 per 100 000 (3.0-3.3). Whites were affected twice more than blacks and men five times more than women. Most patients with GCA were older than 60 years with no increase among younger persons and no birth cohort effect (p=0.99).

CONCLUSION

Several significant epidemiological differences exist between OA and GCA. These differences suggest that these two malignancies are separate entities with different risk factors.

Population-based study of microinvasive adenocarcinoma of the uterine cervix

OBJECTIVE

To analyze lymph node status and survival rates of women with microinvasive cervical adenocarcinoma (International Federation of Gynecology and Obstetrics stages IA(1) and IA(2)).

METHODS

The Surveillance, Epidemiology, and End Results (SEER) Public-Use Database was used to identify cases of microinvasive cervical adenocarcinoma diagnosed between 1988 and 1997. Variables analyzed included stage, extent of surgery, lymph node status, radiation therapy, and age. Statistics included analysis of trends, analysis of variance, log-rank test, one-sided binomial confidence interval estimation, and power analysis.

RESULTS

Among 301 reported cases, 131 had stage IA(1) and 170 IA(2) disease. Simple hysterectomies were done in 54 women with IA(1) and 64 with IA(2) disease and radical hysterectomies were done in 50 and 83 women, respectively. Only one of 140 women who had lymphadenectomy had a single positive lymph node. There were four tumor-related deaths (one with IA(1), and three with IA(2) disease). There were no deaths among 96 women (47, IA(1); 49, IA(2)) treated by simple hysterectomy alone. The mean follow-up was 46.5 months (range 1--119). The censored survival rate was 98.7% overall (99.2% IA(1), 98.2% IA(2)). Power analysis estimated that 720 patients would be required in each group to detect a 2% difference in survival. Using one-sided 95% confidence interval estimations, the risk-adverse events rate for IA(1) was no more than 3.57%, and 4.50% for IA(2) disease.

CONCLUSION

Prognosis is excellent for microinvasive adenocarcinoma of the uterine cervix. In 96 cases (31.9%), simple hysterectomy alone proved adequate.

Trends in Gleason score for prostate cancer diagnosed between 1983 and 1993

PURPOSE

During the 1980s and 1990s the number, incidence rate and proportion of moderately differentiated prostate cancer cases ascertained by population based cancer registries increased substantially. The increase is thought to have resulted from the widespread use of prostate specific antigen (PSA) for screening because it occurred coincidentally with the introduction of PSA for early detection of prostate cancer. We investigate this increase in a population based study.

MATERIALS AND METHODS

To report the trends in tumor grade we conducted a blinded, standardized pathological study and reviewed medial records of a stratified random sample of cases diagnosed before and after the introduction of PSA (1983 to 1984 and 1992 to 1993). Archival tumor biopsy specimens or transurethral resection of the prostate specimens were reviewed for the diagnosis of cancer and assignment of Gleason score. Medical records were reviewed to determine the method of prostate cancer detection for each case.

RESULTS

We found a small but statistically insignificant shift in the distribution of Gleason scores assigned after review of biopsy or transurethral resection specimens. The proportion of Gleason score 2, 3 and 4 tumors decreased, and the proportion of 7, 8, 9 and 10 tumors as a group did not change. The shifts in Gleason score resulted in a slight statistically nonsignificant increase in mean Gleason score. There was a significant shift in the method of detection from predominately incidental detection in the earlier period to predominately screen detection in the later period. Because the proportion of screen detected tumors increased and they had a significantly higher mean Gleason score than incidentally detected tumors within each interval, the overall mean Gleason score increased.

CONCLUSIONS

After a standardized pathological review a small shift in the distribution of Gleason scores occurred resulting in a small increase in mean Gleason score between 1983 and 1984, and 1992 and 1993. There was little change in the proportion of Gleason score 7, 8, 9 and 10 tumors between the 2 periods.

Patterns of mammography use among Hispanic, American Indian, and non-Hispanic White women in New Mexico, 1994-1997

For screening efforts to maximally reduce mortality in the general population, a large proportion of women need to utilize mammography routinely. To investigate utilization of mammography in a community setting, the authors used population-based data collected by the New Mexico Mammography Project for residents of the Albuquerque, New Mexico, metropolitan area for the period 1994-1997. The authors computed screening rates and the proportion of women who routinely use mammography. The utilization of mammography was low. Only 50% of the women aged 50-74 years were screened each year. Less than one third of women aged 40-49 years or 75 years and older were screened annually. The percentage of women who routinely used mammography on an annual or biennial basis was low in all age groups, especially among Hispanics and American Indians. Women aged 50-74 years had the highest percentage of routine annual mammography use, ranging from 30% in non-Hispanic Whites to 20% in Hispanics. Current utilization of mammography in community-based screening efforts is unlikely to achieve a potential 30% reduction in breast cancer mortality. Interventions are needed to increase the routine use of mammography.

The rising incidence of adenocarcinoma relative to squamous cell carcinoma of the uterine cervix in the United States--a 24-year population-based study

OBJECTIVE

The aim of this study was to compare the age-adjusted incidence and survival for invasive adenocarcinoma and squamous cell carcinoma of the uterine cervix using population-based data.

METHODS

The SEER database was used to identify all cases of cervical cancer registered between 1973 and 1996. Stage was defined as localized, regional, or distant. Age-adjusted incidence rates were analyzed statistically using the Jonchkeere-Terpstra exact test for trends. Relative and observed survival rates, respectively, were compared using z tests and log-rank tests.

RESULTS

The age-adjusted incidence rates per 100,000 for all invasive cervical cancers decreased by 36.9% over 24 years [12.35 (1973-1977) vs 7.79 (1993-1996)]. Similarly, the age-adjusted incidence rates for squamous cell carcinoma declined by 41.9% [9.45 (1973-1977) vs 5.49 (1993-1996)]. In contrast, the age-adjusted incidence rates for adenocarcinoma increased by 29.1% [1.34 (1973-1977) vs 1.73 (1993-1996)]. The proportion of adenocarcinoma increased 107.4% relative to all cervical cancer, 95.2% relative to squamous cell carcinoma, and 49.3% relative to the population of women at risk [10. 8% vs 22.4% (P < 0.001), 12.4% vs 24.0% (P < 0.001), and 1.40 vs 2. 09 per 100,000 women (P < 0.001), respectively]. Observed survival rates for adenocarcinoma vs squamous cell carcinoma were poorer for regional (P = 0.04), but not localized or distant disease.

CONCLUSIONS

Over the past 24 years, the incidence of all cervical cancer and squamous cell carcinoma has continued to decline. However, the proportion of adenocarcinoma relative to squamous cell carcinoma and to all cervical cancers has doubled, and the rate of adenocarcinoma per population at risk has also increased. These results suggest that current screening practices in the United States are insufficient to detect a significant proportion of adenocarcinoma precursor lesions.

Biologic characteristics of interval and screen-detected breast cancers

BACKGROUND

Interval breast cancer is defined as a cancer that is detected within 12 months after a negative mammogram. The failure of mammography to detect breast cancer depends on testing procedures, radiologist interpretation, patient characteristics, and tumor properties. Although errors by radiologists explain some interval cancers, another explanation is that the tumor is rapidly growing and was too small to be detected on the last mammogram. To determine whether markers of tumor growth rate are associated with risk of an interval cancer, we conducted a population-based study with the use of data collected statewide by the New Mexico Mammography Project.

METHODS

Among women who received a mammographic examination from 1991 throughout 1993, we ascertained records of all patients with breast cancer diagnosed within 12 months of a negative screening mammographic examination (interval cancers) and corresponding tumor samples, when available. We selected an age- and ethnicity-matched comparison group of control patients with screen-detected breast cancers diagnosed during the same period. In tumor samples, p53, bcl-2, and Ki-67 were examined immunologically and the apoptotic index was assessed histologically. We used logistic regression to determine whether interval cancers were associated with selected demographic, radiologic, and biologic characteristics.

RESULTS

It is more likely that mammography did not detect tumors with a high proportion of proliferating cells (>20%) than tumors with a low proportion of proliferating cells (<5%) (odds ratio [OR] = 4.09; 95% confidence interval [CI] = 1.14-14.65). The OR for mammographic failure was 2.96 (95% CI = 1.07-8.20) among cancers that expressed p53 compared with cancers that did not. Interval cancers also had fewer apoptotic cells. Approximately 75% of interval cancers appear to have tumors with 5% proliferating cells or more. Younger women had a higher proportion of rapidly proliferating and aggressive cancers.

CONCLUSION

Rapidly growing and aggressive tumors account for a substantial proportion of mammographic failure to detect breast cancer, especially among younger women, who have a high proportion of aggressive cancers.

Uranium mining and lung cancer among Navajo men in New Mexico and Arizona, 1969 to 1993

Navajo men who were underground miners have excess risk of lung cancer. To further characterize the long-term consequences of uranium mining in this high-risk population, we examined lung cancer incidence among Navajo men residing in New Mexico and Arizona from 1969 to 1993 and conducted a population-based case-control study to estimate the risk of lung cancer for Navajo uranium miners. Uranium mining contributed substantially to lung cancer among Navajo men over the 25-year period following the end of mining for the Navajo Nation. Sixty-three (67%) of the 94-incident lung cancers among Navajo men occurred in former uranium miners. The relative risk for a history of mining was 28.6 (95% confidence interval, 13.2-61.7). Smoking did not account for the strong relationship between lung cancer and uranium mining. The Navajo experience with uranium mining is a unique example of exposure in a single occupation accounting for the majority of lung cancers in an entire population.

Trends in incidence and treatment for ductal carcinoma in situ in Hispanic, American Indian, and non-Hispanic white women in New Mexico, 1973-1994

BACKGROUND

Incidence rates of ductal carcinoma in situ (DCIS) breast carcinoma and the use of breast-conserving surgery (BCS) for its treatment show substantial geographic and ethnic variations nationwide. To the authors' knowledge, few studies have investigated incidence rates and treatment patterns in Hispanics and American Indians.

METHODS

The authors used data from the population-based New Mexico Tumor Registry to describe trends in DCIS incidence rates between 1973-1994 and investigate patient and physician characteristics related to BCS in a multiethnic population between 1985-1994. Multiple logistic regression was used to evaluate patient and physician factors related to receiving BCS.

RESULTS

Incidence rates for DCIS in Hispanics were approximately 50% lower compared with non-Hispanic whites. American Indians had the lowest incidence rate. Beginning in 1985, incidence rates for Hispanics and non-Hispanic whites showed a 21% annual increase. Between 1990-1994, incidence rates in American Indians increased more than twofold. BCS increased 5.8% per year between 1985-1994, with 50% of Hispanic and non-Hispanic white patients treated with BCS in 1994. The strongest factor associated with receiving BCS was geographic location of treatment (P < 0.001). The odds of receiving BCS were 5.8 times higher in the northern third of the state compared with the southern third. No significant variation in BCS was found by ethnicity, rural/urban residency, socioeconomic status, or physician characteristics.

CONCLUSIONS

Incidence rates for DCIS increased substantially in all three ethnic groups. The use of BCS was associated most strongly with the location of treatment, most likely reflecting differences in physician practices and treatment recommendations. Further research is needed to investigate the increasing incidence rates of DCIS and the determinants of BCS for the treatment of DCIS.

Effects of age, breast density, ethnicity, and estrogen replacement therapy on screening mammographic sensitivity and cancer stage at diagnosis: review of 183,134 screening mammograms in Albuquerque, New Mexico

PURPOSE

To examine how common patient factors affect screening mammographic sensitivity and cancer stage at diagnosis.

MATERIALS AND METHODS

The authors used a population-based database of 183,134 screening mammograms and a statewide tumor registry to identify 807 breast cancers detected at screening mammography.

RESULTS

Sensitivity varied significantly with ethnicity, use of estrogen replacement therapy, mammographic breast density, and age. Sensitivity was 54% (13 of 24) in women younger than 40 years, 77% (121 of 157) in women aged 40-49 years, 78% (224 of 286) in women aged 50-64 years, and 81% (277 of 340) in women older than 64 years. Sensitivity was 68% (162 of 237) for dense breasts and 85% (302 of 356) for nondense breasts and 74% (180 of 244) in estrogen replacement therapy users and 81% (417 of 513) in nonusers. Sensitivity was most markedly reduced with the combination of dense breasts and estrogen replacement therapy use; there was little difference when only one factor was present. Median cancer size and the percentage of early cancers showed little change with any factors.

CONCLUSION

Age is a minor determinant of mammographic sensitivity in women aged 40 years or older. Sensitivity is substantially decreased with the combination of higher breast density and estrogen replacement therapy use. There was not a notable shift in cancer outcomes in the groups with lower mammographic sensitivity. These data do not support different screening recommendations in women aged 40-49 years or in estrogen replacement therapy users.

Evaluating cluster alarms: a space-time scan statistic and brain cancer in Los Alamos, New Mexico

OBJECTIVES

This article presents a space-time scan statistic, useful for evaluating space-time cluster alarms, and illustrates the method on a recent brain cancer cluster alarms in Los Alamos, NM.

METHODS

The space-time scan statistic accounts for the preselection bias and multiple testing inherent in a cluster alarm. Confounders and time trends can be adjusted for.

RESULTS

The observed excess of brain cancer in Los Alamos was not statistically significant.

CONCLUSIONS

The space-time scan statistic is useful as a screening tool for evaluating which cluster alarms merit further investigation and which clusters are probably chance occurrences.

Trends in the survival of American Indian, Hispanic, and Non-Hispanic white cancer patients in New Mexico and Arizona, 1969-1994

BACKGROUND

The burden of cancer mortality falls disproportionately on cancer patients belonging to ethnic minority groups. In the U.S., African American, Hispanic, and American Indian cancer patients are diagnosed at a more advanced stage and receive less appropriate treatment, resulting in poorer outcomes and higher mortality, than white cancer patients. The authors hypothesized that cancer control strategies based on earlier detection and more effective treatment may be most effective in increasing survival in groups with more advanced disease at diagnosis, less appropriate treatment, and lower survival.

METHODS

Data collected by the New Mexico Tumor Registry, a member organization of the Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute, afforded the authors an opportunity to investigate this hypothesis by studying trends in cancer survival for American Indians, Hispanics, and non-Hispanic whites. The authors examined temporal trends and ethnic disparities in survival for in situ and invasive incident cancer cases at 25 sites diagnosed from 1969 through 1994 in New Mexico residents and in American Indians residing in Arizona.

RESULTS

The distribution of stage became more favorable and the percentage of patients receiving appropriate treatment increased for all three ethnic groups during the study period. Survival improved for patients with cancer at most sites in each ethnic group; however, because the increase in survival was greater for non-Hispanic whites than for American Indians or Hispanics, the number of sites associated with disparities in survival among non-Hispanic whites, American Indians, and Hispanics increased. Differences in the distribution of age, gender, stage at diagnosis, histologic grade, and treatment did not completely explain the improved survival or the ethnic disparities regarding survival.

CONCLUSIONS

Increased cancer control efforts were associated with earlier diagnosis, more patients receiving appropriate therapy, and improved survival for non-Hispanic whites, American Indians, and Hispanics. However, the improvement was greatest for non-Hispanic whites, and disparities in survival results for the different ethnic groups widened over the period of study. Cancer control strategies need to address the specific social, cultural, and biologic prognostic factors that affect different ethnic groups if disparities in outcomes are to be reduced.

Increasing incidence of colon and rectal cancer among Hispanics and American Indians in New Mexico (United States), 1969-94

OBJECTIVES

This study evaluates time trends in colon and rectal cancer incidence and mortality among the three major race/ethnic groups (Hispanics, American Indians, and non-Hispanic Whites) in New Mexico (United States).

METHODS

We used data from the New Mexico Tumor Registry (NMTR) and computed average annual age-standardized incidence and mortality rates. Colon cancer incidence rates were further examined by anatomical subsite. Estimated annual percent change (EAPC) in incidence and mortality over time were computed using Poisson regression.

RESULTS

Invasive colorectal cancer incidence rates increased from 1969-89 in all three race/ethnic groups, but decreased among non-Hispanic Whites in 1990-94, while rates continued to increase among minority populations, especially among minority men. Over the 26-year period, EAPC in colon cancer incidence among men was 3.6 percent for Hispanics, 4.7 percent for American Indians, and 0.7 percent for non-Hispanic Whites. Right-sided colon cancers were more common among American Indian women, and among all women aged 65 years and older. Mortality rates decreased steadily among non-Hispanic Whites over the study period, especially among women.

CONCLUSIONS

Studies are needed to identify important modifiable risk factors and to develop strategies to increase the use of colorectal cancer screening-procedures among the minority populations.

Prostate cancer in American Indians, New Mexico, 1969 to 1994

PURPOSE

Prostate cancer is the most frequently diagnosed cancer as well as the leading cause of cancer death among American Indian men.

MATERIALS AND METHODS

To describe further the occurrence of prostate cancer among American Indian men, we examined population based incidence, treatment, survival and mortality data for American Indians in New Mexico during the 25-year period 1969 to 1994.

RESULTS

Although American Indian men have a lower risk of prostate cancer than nonHispanic white men, the incidence and mortality rates are rising for American Indians, and mortality rates are now equal to those for nonHispanic white men. During the 25-year period age adjusted incidence rates for American Indians increased from 42.2/100,000 (95% confidence interval 27.1 to 57.3) to 64.6/100,000 (95% confidence interval 46.2 to 83.0). The burden of prostate cancer among American Indian men compared with nonHispanic white men was reflected in disproportionately high mortality rates in relation to incidence rates. The mortality rates were high because American Indian cases were more advanced at diagnosis, 23.3% of prostate cancers were diagnosed after distant spread had occurred compared with 11.6% for nonHispanic white men and the 5-year relative survival rate was poorer (57.1% compared with 77.6% for nonHispanic white men).

CONCLUSIONS

Effective and culturally sensitive cancer control efforts for prostate cancer in American Indian communities are urgently needed.

Ethnic differences in uterine corpus cancer incidence and mortality in New Mexico's American Indians, hispanics and non-Hispanic whites

BACKGROUND

Although ethnic and radical differences in uterine corpus cancer incidence and mortality have been reported worldwide, few published data have addressed the epidemiology of uterine cancer among US American Indians and Hispanics.

METHODS

We reviewed uterine corpus cancer incidence and survival data from New Mexico's population-based cancer registry collected from 1969 to 1992, and examined State vital records data for uterine cancer deaths collected from 1958 to 1992, focusing on ethnic differences in occurrence and outcomes of uterine malignancies.

RESULTS

Non-Hispanic white women had age-adjusted incidence rates that were substantially higher (20.8 per 100,000) than rates for Hispanics (10.3) and American Indians (6.0) over the 24-year period. Uterine cancer mortality rates were also higher for non-Hispanic whites and Hispanics than for American Indian women, although mortality rates were substantially lower than incidence rates. Five-year survival for uterine cancer was comparable among all groups for all stages combined (87.3% for non-Hispanic whites, 81.4% for Hispanics, and 84.6% for American Indians).

CONCLUSIONS

Our population-based data show ethnic differences in uterine corpus cancer incidence rates for non-Hispanic white women that were double those for Hispanics, and triple those for American Indian women. Ethnic differences in survival were comparable. Aetiologic studies are warranted to investigate the dramatic ethnic differences in occurrence of uterine cancer.

Prognostic factors for thyroid carcinoma. A population-based study of 15,698 cases from the Surveillance, Epidemiology and End Results (SEER) program 1973-1991

BACKGROUND

A number of prognostic factors for thyroid carcinoma have been identified, including sociodemographic characteristics, such as age and gender, and tumor characteristics, such as histology and stage. The relative importance of these factors as independent predictors of survival for patients with papillary, follicular, anaplastic, and medullary thyroid carcinoma has been extensively studied but remains uncertain.

METHODS

The authors used data collected by the Surveillance, Epidemiology and End Results (SEER) program of the National Cancer Institute between 1973 and 1991 to investigate prognostic factors for each of the major histologic types of thyroid carcinoma in a population-based patient series and to assess the effect of these factors as predictors of survival.

RESULTS

Both tumor and sociodemographic characteristics were independently associated with survival. Patients with papillary carcinoma had the highest 10-year relative survival (0.98), followed by those with follicular carcinoma (0.92) and medullary carcinoma (0.80). Anaplastic tumors had the lowest 10-year relative survival (0.13). Stage at diagnosis and differentiation status were strong independent prognostic factors for each histologic type. Advanced stage at diagnosis was a stronger prognostic factor for medullary carcinoma than for other histologic types. Increasing age was associated with lower relative survival for each histologic type. Gender, marital status, and ethnicity were significant, but weaker, predictors of survival.

CONCLUSIONS

Survival varied markedly among patients with different histologic types of thyroid carcinoma. Stage at diagnosis and tumor differentiation were important prognostic factors for each histologic type. Age at diagnosis was a stronger predictor of survival for patients with follicular and medullary carcinoma than for patients with papillary carcinoma.

Prognostic factors for thyroid carcinoma. A population-based study of 15,698 cases from the Surveillance, Epidemiology and End Results (SEER) program 1973-1991

BACKGROUND

A number of prognostic factors for thyroid carcinoma have been identified, including sociodemographic characteristics, such as age and gender, and tumor characteristics, such as histology and stage. The relative importance of these factors as independent predictors of survival for patients with papillary, follicular, anaplastic, and medullary thyroid carcinoma has been extensively studied but remains uncertain.

METHODS

The authors used data collected by the Surveillance, Epidemiology and End Results (SEER) program of the National Cancer Institute between 1973 and 1991 to investigate prognostic factors for each of the major histologic types of thyroid carcinoma in a population-based patient series and to assess the effect of these factors as predictors of survival.

RESULTS

Both tumor and sociodemographic characteristics were independently associated with survival. Patients with papillary carcinoma had the highest 10-year relative survival (0.98), followed by those with follicular carcinoma (0.92) and medullary carcinoma (0.80). Anaplastic tumors had the lowest 10-year relative survival (0.13). Stage at diagnosis and differentiation status were strong independent prognostic factors for each histologic type. Advanced stage at diagnosis was a stronger prognostic factor for medullary carcinoma than for other histologic types. Increasing age was associated with lower relative survival for each histologic type. Gender, marital status, and ethnicity were significant, but weaker, predictors of survival.

CONCLUSIONS

Survival varied markedly among patients with different histologic types of thyroid carcinoma. Stage at diagnosis and tumor differentiation were important prognostic factors for each histologic type. Age at diagnosis was a stronger predictor of survival for patients with follicular and medullary carcinoma than for patients with papillary carcinoma.

Breast cancer survival among New Mexico Hispanic, American Indian, and non-Hispanic white women (1973-1992)

A study of breast cancer survival was conducted among New Mexico Hispanic and non-Hispanic white women and New Mexico and Arizona American Indian women diagnosed between 1973 and 1992. The goals were to determine whether, after adjusting for first treatment and the extent of disease at diagnosis, American Indian and Hispanic women had poorer survival than non-Hispanic whites and, if survival had improved over time, whether comparable improvements had been made for the three racial/ethnic groups. Five-year relative survival rates were calculated, and a Cox proportional hazards model was constructed to compare survival between races/ethnicities, adjusting for first treatment and the extent of disease at diagnosis. Findings indicate that during 1983-1992, breast cancer was more commonly detected at a local stage for all three groups compared to 1973-1982. Five-year relative survival improved for non-Hispanic white and American Indian women with local or regional disease, but the improvement was statistically significant only for non-Hispanic white women and for American Indian women with local disease. Despite earlier stages at diagnosis, Hispanic females showed less improvement in overall or stage-specific survival than non-Hispanic whites. The Cox model indicated that American Indian women experienced poorer survival than non-Hispanic whites during both time periods. Survival of Hispanic women with breast cancer was comparable to non-Hispanic whites during 1973-1982 but was significantly worse during 1983-1992. The significance of this lower survival is amplified by increasing breast cancer incidence among New Mexico Hispanics and American Indians.

The New Mexico Mammography Project. Screening mammography performance in Albuquerque, New Mexico, 1991 to 1993

BACKGROUND

This project was designed to collect and link population-based mammography and breast carcinoma data to assess the performance of community mammography screening.

METHODS

Computerized data were collected from all radiology practices in Albuquerque, New Mexico. The data were linked by computer match to breast carcinomas in a statewide cancer registry. Analysis is based on 126,466 screening mammogram studies performed on 87,443 female residents of New Mexico between the ages of 35 and 84 by 5 radiology groups. Sensitivity, specificity, positive predictive value, and call back rates were calculated as indicators of the discriminative performance of mammography. Carcinoma size and stage distribution were analyzed as outcome measurements.

RESULTS

The computer match linked 634 breast carcinomas to the 126,466 screening mammogram series. The community-wide sensitivity was 79.9%, and specificity was 90.5%. The predictive value of an abnormal screen was 4.3%, and that of a biopsy recommendation result was 16.9%. The call back rate was 11.4%. The median invasive breast carcinoma size was 15 mm, 20.3% of carcinomas were in situ, 18.3% were lymph node positive, and 68.1% were Stage 0 or Stage 1.

CONCLUSIONS

Mass screening mammography as practiced in Albuquerque, New Mexico, is able to detect breast carcinomas at early, treatable stages. The stage distribution of carcinomas is similar to that seen in successful clinical trials. However, measures of mammography performance show lower sensitivity, more additional studies, and more biopsy recommendations in this community setting than have been reported by expert mammographers.

Improving survival for patients with prostate cancer diagnosed in the prostate-specific antigen ERA

OBJECTIVES

Although prostate-specific antigen (PSA) screening has not been demonstrated to reduce prostate cancer mortality in the clinical trial or population setting, the use of PSA for screening increased during the early 1990's. A clinical trial is currently underway to test the efficacy of PSA screening; however, the results will not be available for at least 10 years. To address concerns about the effectiveness of PSA screening in the near term, population-based assessments of PSA screenings are needed. To reduce mortality, PSA screening must first produce improved survival. In New Mexico, increased screening was associated with a stage migration from distant to earlier stages and an increase in 5-year relative survival, suggesting that PSA screening may be effective.

METHODS

To further investigate early indicators of the effectiveness of PSA screening in New Mexico, we examined temporal trends in survival for the period 1983-1992, using proportional-hazard models to estimate the risk of death by year of diagnosis, adjusted for age, stage, grade, ethnicity, and initial treatment.

RESULTS

We found the risk of death following the diagnosis of local or regional-stage prostate cancer decreased in the 1987-1988 (relative-risk [RR] = 0.9 [95% confidence interval (CI) 0.8, 1.1]), 1989-1990 [RR = 0.9 [0.8, 1.0]), and 1991-1992 (RR =0.7 [0.6, 0.9]) periods compared with the 1983-1984 period. Men treated with radical prostatectomy were at increased risk between 1985 and 1990, compared with those treated in the 1983-1984 period. However, for men diagnosed and treated in the 1991-1992 period, risks were lower than in the 1983-1984 period (RR =0.8 [0.4, 1.5]).

CONCLUSIONS

The earlier stage at diagnosis and the improved survival during the period of increased PSA screening are consistent with changes expected from an effective screening test and treatment modality.

Ovarian cancer incidence and mortality in American Indian, Hispanic, and non-Hispanic white women in New Mexico

Although ethnic and racial differences in ovarian cancer incidence and mortality have been reported worldwide, few published data have addressed the epidemiology of ovarian cancer among U.S. American Indians and Hispanics. We reviewed ovarian cancer incidence and survival data from New Mexico's population-based cancer registry collected from 1969 to 1992, and examined state vital records data for ovarian cancer deaths collected from 1958 to 1992, focusing on ethnic differences in occurrence and outcomes of ovarian malignancies. Non-Hispanic white women had age-adjusted incidence rates that were slightly higher (13.3/100,000) than rates for American Indians (11.4) and Hispanics (10.7) over the 24-year period. Ovarian cancer mortality rates were also higher for non-Hispanic whites than for minority women. Neither incidence rates nor mortality rates for ovarian cancer improved over the span of the study period. In addition, the stage at diagnosis did not shift substantially over time for any of the ethnic groups studied, nor did the distribution of various histopathological types shift proportionately. Only slight improvement was observed in 5-year survival over the time period of the study, with greater gains among younger (50 years old or less) versus older women. Ethnic differences in ovarian cancer incidence and mortality were apparent in our population-based data. However, our analysis indicated no reduction in ovarian cancer incidence or mortality in our state over the past quarter century and only slight improvement in 5-year survival.

Ethnic variation in prostate cancer survival in New Mexico

Prostate cancer survival varies markedly by ethnicity. American Indians and blacks have the lowest 5-year relative survival among ethnic groups in the U.S. In New Mexico, relative survival for prostate cancer is lower for ethnic minority groups than for non-Hispanic whites. To examine factors underlying ethnic differences in prostate cancer survival in New Mexico, we analyzed Surveillance, Epidemiology, and End Results Program data collected by the New Mexico Tumor Registry from 1983 to 1992. Unadjusted relative risk (RR) of death after prostate cancer diagnosis was greater for Hispanics [RR = 1.1; 95% confidence interval (CI), 1.0, 1.2], American Indians (RR = 1.4; 95% CI, 1.2, 1.5), and blacks (RR = 1.5; 95% CI, 1.2, 1.7) than for non-Hispanic whites. After adjusting for age, stage, histological grade, year of diagnosis, and initial treatment, the risk for Hispanics (RR = 1.0; 95% CI, 0.9, 1.1), American Indians (RR = 1.0; 95% CI, 0.9, 1.1), and non-Hispanic whites was comparable. Although based on small numbers, adjusted risk ratios among blacks remained elevated (RR = 1.2; 95% CI, 0.9, 1.6), due in part to lower survival during the first 12 months after diagnosis (RR = 2.0; 95% CI, 1.2, 3.3) and poorer survival following radical prostatectomy (RR = 4.2; 95% CI, 1.3, 13). These findings suggest that poorer survival for Hispanics and American Indians may be explained by delayed detection and differences in treatment.

Decreasing rates of cervical cancer among American Indians and Hispanics in New Mexico (United States)

Minority women in New Mexico (United States)--including American Indian and Hispanic women--have shown disproportionately high incidence rates of invasive cervical cancer during the 1960s and 1970s. Several public health programs in New Mexico were directed toward early detection of cervical cellular abnormalities, particularly targeting the state's minority women. To evaluate the effectiveness of these programs, we examined the New Mexico Surveillance, Epidemiology, and End Results (SEER) data collected from 1969-92, and calculated average annual, age-specific, and age-adjusted incidence rates by ethnic group (American Indian, Hispanic, and non-Hispanic White) for five-year time intervals. We also calculated age-adjusted mortality rates for cervical cancer in the same ethnic groups using state vital records. Age-adjusted incidence rates for invasive cervical cancer show substantial temporal decreases, especially for minority women in the state. The age-adjusted incidence rate decreased by 66 percent, from 30.3 to 10.3 per 100,000 for American Indian women, and by 61 percent, from 26.1 to 10.2 per 100,000 for Hispanic women. A stage shift to earlier stages of cervical neoplasia occurred over the study period, with a substantially higher proportion of in situ compared with invasive cancers diagnosed in the most recent cf the most remote time period. The ratio of incidence rates of in situ to invasive cancers changed dramatically for both American Indian and Hispanic women. Cervical cancer mortality rates decreased steadily among Hispanic women from 1958 to 1992; the decrease among American Indian women was less stable and fluctuated due to small numbers. Ongoing targeted screening programs should help to reduce cervical cancer incidence and mortality further in New Mexico.

Trends in alcohol-related mortality among New Mexico's American Indians, Hispanics, and non-Hispanic whites

Reduction of alcohol-related mortality is a national goal for health promotion and disease prevention. We conducted this analysis to determine whether trends in New Mexico's Hispanics, non-Hispanic Whites, and American Indians were consistent with national trends in alcohol-related mortality, and whether differences in drinking patterns could account for racial and ethnic differences in rates. Age-adjusted, race-specific, and ethnic-specific alcohol-related mortality rates and 95% confidence intervals were calculated for 5-year periods for 1958-1991 using New Mexico vital statistics data. We estimated the prevalence of acute and chronic at-risk drinking behaviors and abstinence from data collected by the Behavioral Risk Factor Surveillance System (BRFSS) for the period 1986-1992. We found that alcohol-related mortality rates varied substantially by race, ethnicity, sex, age, and calendar period. American Indians had the highest rates for both sexes. Rates increased sharply from the period 1958-1962 until the late 1970s and the early 1980s, and then began to decrease rapidly. However, during the most recent decade, the rates have followed contrasting trends in the three ethnic and racial groups. Although rates have continued to decline among non-Hispanic Whites, rates for Hispanics and American Indians have not declined, and still remain substantially higher than rates during the 1958-1962 period. Differences in at-risk drinking behaviors reported to the BRFSS do not explain the contrast in race-specific and ethnic-specific mortality rates. Although progress has been made in reducing national per capita alcohol consumption and alcohol-related mortality, certain high-risk racial and ethnic groups may not be sharing in the progress.

Breast mammographic pattern: a concatenation of confounding and breast cancer risk factors

A mammographic pattern of > 25% radiodensity is associated with increased risk for breast cancer. Mammographic pattern is influenced by age, body weight, reproductive factors, and race/ethnicity. The interaction among these factors in predicting breast radiographic pattern, and their association with the presence of histologic markers of increased risk of breast cancer, is poorly defined. To elucidate the relations among epidemiologic, radiographic, and histologic markers of breast cancer risk, the authors studied these factors in an unselected forensic autopsy series, accumulated between 1978 and 1983, of 486 women aged 15-98 years at death. Older age and/or postmenopausal status was the strongest predictor of radiolucent breast pattern. Obesity, defined as a Quetelet index (weight(kg)/height(m)2) of > 25, and large breast size were also highly significant predictors of breast radiolucency. Factors related to parity were not significant predictors of breast parenchymal pattern. Native American race was an independent predictor of breast radiolucency in this population. A dense parenchymal pattern was associated with increased prevalence of marked cystic change and the presence of duct epithelial hyperplasia in women under age 35. The results support the association of breast radiodensity with ethnic/racial, reproductive, and histologic factors predictive of cancer risk. However, this association is overshadowed by the effects of obesity and aging or menopause.

Rapid rise and subsequent decline in prostate cancer incidence rates for New Mexico, 1989-1993

Beginning in the late 1980s, a large increase in incidence rates for prostate cancer occurred in association with increased prostate-specific antigen (PSA) screening. In New Mexico, the increased screening was associated with earlier detection of cancers and decreased prostate cancer mortality, suggesting that PSA screening may be effective. PSA screening has become a controversial topic of public debate, and anecdotal reports from physicians indicated that prostate cancer screening practice patterns were changing in New Mexico. To assess whether PSA-associated trends in prostate cancer incidence were continuing, we examined incidence rates from 1989 to 1993 among men in New Mexico. From 1989 to 1992, age-adjusted rates increased substantially for non-Hispanic whites (77%), Hispanics (50%), and American Indians (27%). Although rates increased for all stages combined, incidence rates decreased for distant-stage disease, especially for non-Hispanic whites, indicating a continuing trend toward earlier detection. In 1993, incidence rates unexpectedly decreased from 203 to 158/100,000 in non-Hispanic whites, largely as a result of changes in rates in men over age 65 years. Although incidence rates decreased, the trend toward earlier detection was maintained for non-Hispanic whites. In contrast, among Hispanic and American Indians, rates did not change substantially between 1992 and 1993. Because the epidemic in prostate cancer was associated with increased PSA screening, it is likely that the trends for non-Hispanic whites are also related to PSA screening. We suggest that the decrease in rates and the continued stage shift are consistent with repeated screening of men in the population at risk.

Male genital cancers

BACKGROUND

The estimated 165,000 cancers of the male genital system that will occur in the United States during 1993 represent one fourth of the expected 600,000 newly diagnosed cancers in American males for the year.

METHODS

Data were collected by the Surveillance, Epidemiology, and End Results (SEER) program. This paper examines histologic data collected by the SEER program from 1973-1987 and focuses on incidence, stage at diagnosis, and survival for the dominant histologic types of cancer that occur in the four major topographic divisions of the male genital system: prostate gland, testis, penis, and scrotum. Some less common histologic types within each organ are also discussed.

RESULTS

The incidence of male genital cancer has increased rapidly over the period of study. Cancers of the prostate, most of which are adenocarcinomas, represent more than 92% of all male genital cancers. Among adolescents and young men, germ cell cancers of the testis predominate, but decline rapidly in occurrence after 40 years of age. Blacks had higher incidence rates for prostate cancer than whites; however, the situation was reversed for testicular cancer. Survival increased dramatically for testicular cancer. Cancers of the penis and scrotum of any histologic type are uncommon in the United States.

CONCLUSIONS

The increased incidence of prostate adenocarcinomas and testis germ cell tumors indicates the need for further etiologic studies as a basis for prevention efforts.

A population-based autopsy study of sudden, unexpected deaths from natural causes among persons 5 to 39 years old during a 12-year period

All unexpected deaths in New Mexico from 1977 to 1988 were reviewed. By statute each such death must be reported to the Office of the Medical Examiner (OMI) and according to institutional policy autopsied even when death is presumed to be from natural causes. From this group the 650 index cases that form the basis of this report were obtained. The crude rate of sudden, unexpected death among New Mexico residents 5 to 39 years old during the study period was 6.6/100,000 persons at risk. As documented by autopsy, the underlying cause of death in a majority of these cases (53.4%) was related to cardiovascular disease and alcoholism. Male persons in general are at increased risk for sudden, unexpected death, and American Indian and black male persons are at greater risk than their Anglo and Hispanic counterparts. American Indians account for a disproportionate share of the unexpected deaths resulting from alcoholism, and black male persons are at particular risk for unexpected death resulting from cardiovascular diseases. This report emphasizes the importance of life style and diet in the well-being of persons 5 to 39 years old.

Contrasting trends of prostate cancer incidence and mortality in New Mexico's Hispanics, non-Hispanic whites, American Indians, and blacks

BACKGROUND

Prostate cancer has increased in epidemic proportions during the 1980s. Although marked differences in ethnic and racial temporal trends for prostate cancer have been observed both in the United States and internationally, the trends in Hispanics and American Indians have not been described extensively.

METHODS

To characterize the occurrence of prostate cancer among non-Hispanic whites, Hispanics, American Indians, and blacks in New Mexico, the authors examined cancer incidence data collected by the New Mexico Tumor Registry for the period 1969-1991 and mortality data collected by the New Mexico Bureau of Vital Statistics for the period 1958-1991.

RESULTS

From 1969 to 1991, age-adjusted incidence rates increased from 74.4 to 139.1 per 100,000 (87%) among non-Hispanic whites and from 54.0 to 94.7 (75%) among Hispanics. American Indians had the lowest incidence rates of all groups. Over the same period, incidence rates for local-stage cancers increased by 93% and 81% among non-Hispanic whites and Hispanics, respectively, but were stable for American Indians and blacks, whereas rates for regional-stage cancers increased sharply. Incidence rates of distant-stage disease decreased among non-Hispanic whites from 1969 through 1991. In contrast, incidence rates of distant-stage disease among Hispanics increased through 1982. From 1983 to date, age-adjusted mortality rates of prostate cancer decreased among all groups except Hispanics.

CONCLUSION

The patterns of incidence and mortality are consistent with a stage migration. The recent decrease in age-adjusted prostate cancer mortality rates for non-Hispanic whites is consistent with that expected following the decrease in distant-stage disease incidence. Differential access to medical care and prostate cancer screening may account for these trends.

Breast cancer among Hispanics, American Indians and non-Hispanic whites in New Mexico

Variation in breast cancer occurrence among women in New Mexico's three major ethnic groups has not previously been assessed. The address the descriptive epidemiology of breast cancer in New Mexico Hispanics, American Indians, and non-Hispanic whites, we calculated incidence rates from population-based registry data covering 1969-1987 and mortality data collected from 1958 to 1987. Breast cancer incidence and mortality rates for New Mexico's non-Hispanic white women were comparable to those for white women nationwide. In contrast, American Indian women had extremely low incidence and mortality rates for breast cancer; rates for Hispanics were intermediate, but well below those for non-Hispanic white women throughout the study period. Pronounced temporal trends in breast cancer occurrence were evident among Hispanic women, with the incidence rate increasing by 56% over the 19 years of available data and the mortality rate increasing by nearly 100% over 30 years. Age-specific incidence and mortality rates increased at all ages for successive birth cohorts of Hispanic women. For non-Hispanic whites, increasing incidence and mortality rates were also observed, but the increments were much smaller, approximately 15% for incidence and 30% for mortality. Our data show substantial ethnic differences in breast cancer incidence and mortality in New Mexico, suggesting the need for aetiological investigations to assist in controlling this disease.

Trends in prostate cancer incidence and mortality in New Mexico are consistent with an increase in effective screening

The increasing occurrence of prostate cancer in the United States has led to recommendations for routine prostate cancer screening in men aged 50 years and older. Although present methods of prostate cancer screening have not been shown to reduce mortality, screening using digital rectal examination or prostate-specific antigen does detect tumors at earlier stages. To assess whether trends in incidence and mortality rates are consistent with an increase in effective screening in New Mexico, we examined prostate cancer incidence rates calculated from data collected by the New Mexico Tumor Registry for the years 1969-1991, and mortality rates calculated from data collected by the New Mexico Bureau of Vital Statistics for the years 1958-1991. Population-based measures of prostate cancer screening frequency in New Mexico are not available for the period of this study; however, the proportion of prostate cancers detected by screening, as documented by a review of records from a random sample of prostate cancer cases, increased 3-fold, from 13% during the 1969-1972 period to 41% in the 1988-1991 period. During the period of study, age-adjusted incidence rates increased from 66.3 to 122.3/100,000 men. Stage migration from distant to earlier stages was apparent in the increase in the proportion of early stage cancers from 77.5 to 85.5%, and the decrease of distant stage cancers from 21.2 to 9.8%. Stage-specific incidence rates increased for local (87.3%) and regional stage cancers (283.0%), and decreased for distant stage cancers (16.0%).(ABSTRACT TRUNCATED AT 250 WORDS)

Cancer mortality among New Mexico's Hispanics, American Indians, and non-Hispanic Whites, 1958-1987

BACKGROUND

Racial and ethnic differences in cancer incidence and mortality are well documented. New Mexico's ethnically and racially diverse population provides an opportunity to further examine ethnic and racial differences in cancer occurrence.

PURPOSE

To address differences in cancer mortality among the state's Hispanics, American Indians, and non-Hispanic Whites, we examined mortality data collected from 1958 through 1987.

METHODS

Sex and age-specific and age-adjusted cancer mortality rates were calculated for all sites and specific sites for American Indians, Hispanics, and non-Hispanic Whites. From 1958 through 1987, deaths due to malignant neoplasms were coded according to the International Classification of Diseases. The categories of malignant neoplasms investigated were chosen, in part, to minimize bias due to changes in disease classification. Ethnicity was assigned by the Bureau of Vital Statistics on the basis of information on death certificates. Denominators were derived from the censuses of 1960, 1970, 1980, and 1990. Age-standardized mortality rates were calculated for 5-year periods (1958-1962, 1963-1967, 1968-1972, 1973-1977, 1978-1982, and 1983-1987), with the 1970 U.S. population as the standard. We also examined age-specific rates by time period.

RESULTS

Within each of New Mexico's ethnic groups, overall cancer mortality increased over the 30-year time span, and the cancer mortality rates were greater for males than for females. For most major cancer sites, mortality rates for New Mexico's non-Hispanic Whites were comparable with data for U.S. Whites. American Indians had the lowest rates for most sites, whereas cancer mortality rates for most sites among Hispanics were intermediate between the two other groups. However, Hispanics and American Indians had higher mortality rates for cancers of the gallbladder, cervix, and stomach compared with non-Hispanic Whites throughout most of the study period. Several other cancer sites showed major mortality rate differences among these racial and ethnic groups, including cancers of the colon, rectum, breast, bladder, lung, ovary, and uterus. We also observed strong temporal trends of increasing or decreasing mortality rates for several cancer sites.

CONCLUSIONS

Race and ethnicity have been strong determinants of cancer mortality in New Mexico. Within the span of one generation, cancer mortality has changed substantially for some cancer sites in each of the population groups studied.

IMPLICATIONS

These mortality data underscore the need for appropriately designed etiologic studies of cancer in diverse racial and ethnic groups. Such etiologic studies could provide new insights concerning risk factors for cancer and useful data for developing race- and ethnic-specific cancer control strategies.

Diabetes mortality among New Mexico's American Indian, Hispanic, and non-Hispanic white populations, 1958-1987

OBJECTIVE

To determine the diabetes-related mortality rates among New Mexico's American Indians, Hispanics, and non-Hispanic whites over a 30-yr period.

RESEARCH DESIGN AND METHODS

Death certificates were used to identify diabetes as an underlying cause of death by ethnic group in New Mexico during each 5-yr period from 1958 through 1987. The age-adjusted rates were calculated by ethnic group and sex, and temporal trends were examined. Comparison was made to U.S. white age-adjusted rates during the same time period.

RESULTS

Age-adjusted diabetes mortality rates for American Indians and Hispanics increased throughout the 30-yr period, and far exceeded rates for New Mexico non-Hispanic whites and U.S. whites by the 1983-1987 time period. The rates increased most dramatically among the state's American Indians, increasing 550% among women and 249% among men. Hispanic women and men experienced increases of 112 and 140%, respectively.

CONCLUSIONS

New Mexico's American Indian and Hispanic populations have higher diabetes mortality rates than non-Hispanic whites, and American Indian mortality rates have risen dramatically over the 30-yr period included in our study. Although the high prevalence of diabetes in American Indians and Hispanics is a major contributor to these rates, other factors may also influence the reported mortality rates.

Changing trends in mortality among New Mexico's American Indians, 1958-1987

Health care availability and living conditions have improved substantially for American Indians in New Mexico over the past quarter century. To investigate the impact of these changes on health statistics, we examined mortality data collected from 1958 to 1987 for American Indians in the state. We analysed the data for all causes of death combined and for specific causes, and compared these data with figures for nonHispanic whites in the state. Age-adjusted mortality rates were calculated for 5-year periods for each ethnic-gender group, using denominators from US Census reports. Mortality rates for all causes combined did not improve significantly for American Indian males from 1958 to 1987, although the rates for American Indian females showed an 8% decline. Infectious disease-related mortality rates for American Indians decreased dramatically over the 30-year study period; however, mortality rates for cancer and diabetes increased over the 30-year period. Mortality rates for injuries and alcoholism among American Indians increased greatly from 1958 to 1977 and then declined later in the study period, but they were consistently higher than rates for whites. The study indicates that several chronic diseases remain of major public health importance for New Mexico's American Indian population.

Improvement in mammography interpretation skills in a community radiology practice after dedicated teaching courses: 2-year medical audit of 38,633 cases

The authors conducted a complete audit of results of 38,633 mammographic examinations performed by 12 general radiologists during a 2-year period with a computerized reporting system. During this period, 11 group members attended 17 dedicated mammography courses. Audit results were analyzed for each radiologist and the entire group. In the 2nd year, the number of breast cancers diagnosed increased 50% (from 121 to 181), with a 6.5% increase in patient volume. Sensitivity increased from 80% to 87%, and there was no change in the positive predictive value of 32%. Median tumor size and node positivity decreased. Most major variables of population and technical factors were unchanged. Diagnostic approach was altered during the 2nd year, as shown by a 50% increase in the use of spot compression, magnification views, and sonography. Analysis of each radiologist's performance before and after attending mammography courses showed similar changes. These data suggest that dedicated mammography courses can help improve radiologists' performance and alter their interpretive approach.

Cervical cancer incidence and mortality in New Mexico's Hispanics, American Indians, and non-Hispanic whites

High rates of cervical cancer were reported in New Mexico in the early 1970s, with especially high rates for minority women. We examined data collected from 1970 to 1987 for invasive cervical cancer and cervical carcinoma in situ for New Mexico's Hispanic, American Indian, and non-Hispanic white women to determine whether changes had occurred in cervical cancer rates since earlier reports. To further characterize the epidemiology of cervical cancer in New Mexico, we reviewed state vital statistics for cervical cancer deaths occurring between 1958 and 1987. From 1970 to 1987, the incidence for invasive cervical cancer among Hispanic (18.9 per 100,000 person-years) and American Indian women (22.0 per 100,000 person-years) was about double that for non-Hispanic white women (10.3 per 100,000). The incidence in each ethnic group decreased over time for both invasive cancer and carcinoma in situ when the data were examined by 2 time periods (1970 to 1978 and 1979 to 1987). These decreases were most dramatic for invasive cervical cancer. Cervical cancer-related death rates for Hispanics and non-Hispanic whites also decreased from 1958 to 1987. Although our data reflect declines in cervical cancer rates during the study period, further rate decreases, especially for minority women, remain an important public health goal in New Mexico.

Parity factors and prevalence of fibrocystic breast change in a forensic autopsy series

The relationship of reproductive factors, such as nulliparous vs ever-parous status, age at first birth, and total parity, with morphologic prevalence of fibrocystic changes were examined using autopsy material from three ethnic/racial groups at varying risks for breast cancer. Although there was a trend toward a protective effect of ever-parous status, there was no statistically significant difference in the prevalence of fibrocystic disease in any group defined by parity status. The ethnic differences in the prevalence of fibrocystic changes were not explained by the differences in parity status distribution for the three ethnic/racial groups.

Survival of children and adolescents with acute lymphoid leukemia. A study of American Indians and Hispanic and non-Hispanic whites treated in New Mexico (1969 to 1986)

During the period 1969 to 1986, 196 American Indian and Hispanic and non-Hispanic white children and adolescents (ages, 0 to 19 years) were treated for acute lymphoid leukemia (ALL) at the University of New Mexico affiliated institutions. There were 28 American Indians (14%), 91 Hispanic whites (46%), and 77 non-Hispanic whites (39%). Median survivals for patients undergoing antileukemic therapy ranged from 8 months for American Indian boys to 140 months for non-Hispanic white girls. American Indian boys had the highest initial median leukocyte count (WBC) at 23.8 X 10(9)/l. Compliance problems occurred most commonly among American Indian children of both genders. Other clinical and pathologic features evaluated in this study were distributed similarly among the ethnic gender groups. Multi-variate analysis revealed that independent prognostic variables for survival included initial WBC, age, and gender. Ethnicity and compliance problems were possible, but confounded, prognostic variables. To the authors' knowledge this represents the most comprehensive study to date of ALL in American Indian patients.

Symptoms, signs, and ill-defined conditions: a leading cause of death among minorities

The Manual of the International Classification of Diseases, Injuries, and Causes of Death includes the category, "symptoms, signs, and ill-defined conditions" for nonspecific causes of death. To determine whether this categorization of cause of death is commonly applied to New Mexico's minority populations, the authors examined state vital records data for 1958-1982. Age-specific and age-adjusted death rates were calculated by 5-year intervals for Hispanics, American Indians, and non-Hispanic whites. Death rates attributed to symptoms, signs, and ill-defined conditions in all three major ethnic groups in New Mexico far exceeded the national rate for whites. For males in the period 1978-1982, American Indians had the highest rates (115.6 per 100,000 males), followed by Hispanics (58.3 per 100,000 males), and non-Hispanic whites (49.2 per 100,000 males); the national rates were 41.3 and 13.1 per 100,000 males for blacks and whites, respectively. Comparable differences were observed among females. The authors suggest that the death rate for deaths attributed to symptoms, signs, and ill-defined conditions may be a potential indicator of access to and use of health services and that the categorization may strongly affect cause-specific death rates in minority populations.

Mortality from infectious diseases among New Mexico's American Indians, Hispanic whites, and other whites, 1958-87

To examine ethnic differences in infectious disease-related mortality in New Mexico's American Indian, Hispanic White and other White populations, we analyzed vital records data from 1958 to 1987. We found that for most infectious causes, American Indians had the highest mortality rates, followed by Hispanics. The state's minority populations remain at increased risk for infectious disease mortality.

Toward a population-based assessment of death due to pulmonary embolism in New Mexico

During a 5-year period (1981 through 1985), 586 of 46,512 (1.26%) deaths in New Mexico had pulmonary embolism (PE) listed on the death certificate. The frequency of death due to PE was mentioned more frequently in the autopsied than in the non-autopsied component of the study (2.4% v 1.1%). This observation, together with published data on the accuracy of clinical diagnostics among persons dying with autopsy-documented PE, suggests that the frequency of death due to this disease is considerably higher than previously thought. Among autopsied persons who died of PE, risk factors and associated diseases are not appreciably different for those who die in or out of the hospital. Important associations with respect to persons dying of PE include male gender, advanced age, serious medical or surgical disease, immobilization, and trauma.

Injury mortality in American Indian, Hispanic, and non-Hispanic white children in New Mexico, 1958-1982

Childhood fatalities from injuries are a serious public health problem in New Mexico, a state which ranks second in the nation in injury-related mortality rates. To determine the extent of injury mortality in children in this state, and to examine time trends and differences in mortality rates in New Mexico's American Indian, Hispanic, and non-Hispanic white children aged 0-14 years, we analyzed vital records collected from 1958 to 1982. American Indian children experienced the highest mortality rates from all external causes combined. Among all three major ethnic groups, children aged 0-4 years were at the highest risk for injury fatalities. Unintentional injuries accounted for 85% of all injury-related deaths. Motor vehicle crashes and drowning were the first and second leading causes of death in all three groups, while other important causes of death included fire, choking on food or other objects, poisoning, and homicide. Although the fatality rates on most types of injuries decreased over the 25-year period, childhood fatality rates for motor vehicle crashes and homicide increased in each ethnic group. Despite the overall decrease in injury mortality rates in New Mexican children, the rates are excessively high compared to other states, especially in American Indian children.

Changes in surgical treatments: the example of hysterectomy versus conization for cervical carcinoma in situ

From 1969 through 1985, 4584 women in the state of New Mexico were diagnosed with carcinoma in situ of the cervix. Of these women, 65.5% underwent hysterectomy while 31.1% had a conservative therapy (primarily conization). Over the 17-year period, there was a steady increase in the percentage of women receiving conservative therapies, from 11.8% in 1969 to 50.3% in 1985. Younger women, unmarried women and American Indian women were more likely to receive conservative therapy. This marked shift in therapeutic approach occurred during a time of apparent controversy as to the optimal treatment for cervical carcinoma in situ, and illustrates a rapid change in surgical practice in the absence of any controlled trials comparing the two major treatment modalities.

Violent death in the West: suicide and homicide in New Mexico, 1958-1987

We examined New Mexico vital statistics data for suicides and homicides among the state's Hispanics, Native Americans, and non-Hispanic whites collected from 1958 to 1987. We found high age-adjusted rates for both suicides and homicides among Hispanic and Native American males, in comparison with rates for non-Hispanic white males. Suicide rates among Native American women were comparatively low, contrasting with their high homicide rates. Homicide rates for males in all three ethnic groups increased substantially over the 30-year study period. We conclude that death from violent causes, both suicide and homicide, is a major public health problem in New Mexico, and disproportionately affects minority males.

Injury mortality in New Mexico's American Indians, Hispanics, and non-Hispanic whites, 1958 to 1982

New Mexico has extraordinarily high injury mortality rates. To better characterize the injury problem in New Mexico, we calculated proportionate injury mortality and age-adjusted and age-specific injury mortality rates for the state's 3 major ethnic groups--American Indians, Hispanics, and non-Hispanic whites. According to death certificate data collected from 1958 to 1982 and US population census figures, age-adjusted mortality rates for total external causes varied widely between the sexes and among the ethnic groups. Males in each ethnic group consistently had higher average annual age-adjusted external mortality rates than females. Injury mortality rates for American Indians of both sexes were 2 to 3 times higher than those for the other New Mexico ethnic groups. Motor vehicle crashes were the leading cause of death from injury for all 3 groups. Homicide accounted for twice the proportion of injury death in Hispanic compared with non-Hispanic white males (12.5% and 6.1%, respectively), while the proportion of males dying of suicide was highest in non-Hispanic whites. Deaths from excessive cold and exposure were leading causes of injury mortality for American Indians, but these causes were not among the leading causes of injury mortality for Hispanics or non-Hispanic whites. We conclude that the minority populations in New Mexico are at high risk for injury-related death and that the major causes of injury mortality vary substantially in the state's predominant ethnic populations.

The sensitivity and specificity of clinical diagnostics during five decades. Toward an understanding of necessary fallibility

Published studies encompassing more than 50,000 autopsies were assessed to determine the sensitivity and specificity of clinical diagnostics (the diagnostic process) in persons dying of 1 of 11 specific diseases during the period 1930 through 1977. The accuracy of clinical diagnostics, as reflected in these two determinations, appeared to improve over this period with respect to some of the diseases studied (rheumatic heart disease and leukemia), while for others it worsened (pulmonary tuberculosis, peritonitis, carcinoma of the lung, gastric carcinoma, and carcinoma of the liver and extrahepatic biliary tract) and for a significant number diagnostic accuracy seemed refractory to sustained change (pulmonary embolism, primary cirrhosis of the liver, gastric/peptic ulcer, and acute coronary thrombosis/myocardial infarction). The findings suggest a new way in which the autopsy can be used to monitor clinical diagnostics to identify possible sources of systematic weaknesses and provide data that can be used to approach the difficult subject of necessary fallibility.