Waning Vaccine Protection against Influenza among Department of Defense Adult Beneficiaries in the United States, 2016–2017 through 2019–2020 Influenza Seasons

The objective of this study was to assess inactivated influenza vaccine effectiveness (VE) by time since vaccination in adults aged ≥ 18 years using a test-negative design. All data were obtained from the US Department of Defense Global Respiratory Pathogen Surveillance Program over four influenza seasons, from 2016–2017 through 2019–2020. Analyses were performed to estimate VE using a generalized linear mixed model with logit link and binomial distribution. The adjusted overall VE against any medically attended, laboratory-confirmed influenza decreased from 50% (95% confidence interval (CI): 41–58%) in adults vaccinated 14 to 74 days prior to the onset of influenza-like illness (ILI), to 39% (95% CI: 31–47%) in adults vaccinated 75 to 134 days prior to the onset of ILI, then to 17% (95% CI: 0–32%) in adults vaccinated 135 to 194 days prior to the onset of ILI. The pattern and magnitude of VE change with increasing time since vaccination differed by influenza (sub)types. Compared to VE against influenza A(H1N1)pdm09 and influenza B, the decrease of VE against influenza A(H3N2) was more pronounced with increasing time since vaccination. In conclusion, based on the analysis of 2536 influenza-positive cases identified from 7058 adults over multiple influenza seasons, the effectiveness of inactivated influenza vaccine wanes within 180 days after 14 days of influenza vaccination.

Circulating Trends of Influenza and Other Seasonal Respiratory Viruses among the US Department of Defense Personnel in the United States: Impact of the COVID-19 Pandemic

The objective of this study was to evaluate the impact of the COVID-19 pandemic on the circulation of influenza and other seasonal respiratory viruses in the United States. All data were obtained from the US Department of Defense Global Respiratory Pathogen Surveillance Program over five consecutive respiratory seasons from 2016-2017 through to 2020-2021. A total of 62,476 specimens were tested for seasonal respiratory viruses. The circulating patterns of seasonal respiratory viruses have been greatly altered during the pandemic. The 2019-2020 influenza season terminated earlier compared to the pre-pandemic seasons, and the 2020-2021 influenza season did not occur. Moreover, weekly test positivity rates dramatically decreased for most of the seasonal respiratory viruses from the start of the pandemic through spring 2021. After the easing of non-pharmaceutical interventions (NPIs), circulations of seasonal coronavirus, parainfluenza, and respiratory syncytial virus have returned since spring 2021. High rhinovirus/enterovirus activity was evident throughout the 2020-2021 respiratory season. The findings suggest a strong association between the remarkably changed activity of seasonal respiratory viruses and the implementation of NPIs during the COVID-19 pandemic. The NPIs may serve as an effective public health tool to reduce transmissions of seasonal respiratory viruses.

Inactivated influenza vaccine effectiveness among department of defense beneficiaries aged 6 months-17 years, 2016-2017 through 2019-2020 influenza seasons

A test-negative case-control study was conducted to assess inactivated influenza vaccine effectiveness (VE) in children aged 6 months-17 years. The database was developed from the US Department of Defense Global Respiratory Pathogen Surveillance Program over four consecutive influenza seasons from 2016 to 2020. A total of 9,385 children including 4,063 medically attended, laboratory-confirmed influenza-positive cases were identified for VE analysis. A generalized linear mixed model with logit link and binomial distribution was used to estimate the VE. The adjusted VE for children was 42% [95% confidence interval (CI): 37-47%] overall, including 55% (95% CI: 47-61%) for influenza A(H1N1)pdm09, 37% (95% CI: 28-45%) for influenza A(H3N2), and 49% (95% CI: 41-55%) for influenza B. The analysis by age groups indicated that the adjusted VE in children aged 6 months-4 years was higher against influenza A(H1N1)pdm09 and influenza B, and comparable against influenza A(H3N2), compared to those in children aged 5-17 years. Further age-stratified analysis showed that the VE against any types of influenza was low and non-significant for children aged 6-11 months (33%; 95% CI:-2-56%), but it was high (54%; 95% CI: 34-67%) in children aged 12-23 months, and then declined linearly with increasing age. In conclusion, the inactivated influenza vaccination was moderately effective against influenza infection, based on the analysis from a large number of children aged 6 months-17 years over multiple influenza seasons.

Influenza Surveillance Trends and Influenza Vaccine Effectiveness Among Department of Defense Beneficiaries During the 2019-2020 Influenza Season

Laboratory-based influenza surveillance was conducted in the 2019-2020 influenza season among Department of Defense (DoD) beneficiaries through the DoD Global Respiratory Pathogen Surveillance Program (DoDGRS). Sentinel and participating sites submitted 28,176 specimens for clinical diagnostic testing. A total of 5,529 influenza-positive cases were identified. Starting at surveillance week 45 (3-9 November 2019), influenza B was the predominant influenza type, followed by high activity of influenza A(H1N1)pdm09 three weeks thereafter. Both influenza B and influenza A(H1N1)pdm09 were then highly co-circulated through surveillance week 13 (22-28 March 2020). End-of-season influenza vaccine effectiveness (VE) was estimated using a test-negative case-control study design. The adjusted end-of-season VE for all beneficiaries, regardless of influenza type or subtype, was 46% (95% confidence interval: 40%-52%). The influenza vaccine was moderately effective against influenza viruses during the 2019-2020 influenza season.

Malignancy in U.S. Air Force fighter pilots and other officers, 1986-2017: A retrospective cohort study

OBJECTIVE

This study sought to determine the incidence rates of cancer, overall and by site, among active component U.S. Air Force fighter pilots, and to compare the rates with those in other active component Air Force officers.

METHODS

Using a matched retrospective cohort design, U.S. Air Force fighter pilots were compared with other commissioned officers who entered active component service between 1 January 1986 and 31 December 2006. The cohort was followed for cancer diagnoses in TRICARE and the Veterans Health Administration from 1 October 1995 through 31 December 2017. Fighter pilots and non-fighter pilot officers were compared after matching on sex, age at first observation (15 age groups), and age at last observation (15 age groups). Sex-stratified overall and site-specific cancer rates were compared with matched Poisson regression to determine incidence rate ratios with 95% confidence intervals.

RESULTS

During 1,412,590 person-years of follow-up, among the study population of 88,432 service members (4,949 fighter pilots and 83,483 matched officers), 977 incident cancer cases were diagnosed (86 in fighter pilots and 891 in matched officers). Male fighter pilots and matched officers had similar rates of all malignant cancers (RR = 1.04; 95% CI: 0.83-1.31) and of each cancer site. Female fighter pilots and matched officers also had similar rates of all malignant cancers (RR = 0.99; 95% CI: 0.25-4.04).

DISCUSSION

In the active component U.S. Air Force, fighter pilots and their officer peers had similar overall and site-specific cancer rates.

Respiratory pathogen surveillance trends and influenza vaccine effectiveness estimates for the 2018-2019 season among Department of Defense beneficiaries

This report primarily focuses on the data collected and analyzed from the worldwide network of sentinel military treatment facilities chosen to participate in the Department of Defense Global Respiratory Pathogen Surveillance (DoDGRS) program. Sites that participated in the 2018-2019 DoDGRS program submitted 24,320 respiratory specimens for diagnostic testing. Clinical results showed a total of 5,968 positive influenza cases. In the beginning of the season, starting in surveillance week 48, influenza A(H1N1)pdm09 was the predominant subtype. The predominant subtype switched to influenza A(H3N2) beginning in week 6 and continued through the end of the season. Influenza B virus detection was less common during the surveillance period (i.e., 1% of total submitted specimens and 5% of total influenza detected). In addition to routine surveillance, the DoDGRS program also conducts vaccine effectiveness (VE) studies twice per year to determine interim and end of season estimates. Overall, the adjusted end of season VE for all dependents regardless of influenza type was 30% (95% CI: 22%-38%).

Positive predictive value of an algorithm used for cancer surveillance in the U.S. Armed Forces

Recent large-scale epidemiologic studies of cancer incidence in the U.S. Armed Forces have used International Classification of Disease, 9th and 10th Revision (ICD-9 and ICD-10, respectively) diagnostic codes from administrative medical encounter data archived in the Defense Medical Surveillance System. Cancer cases are identified and captured according to an algorithm published by the Armed Forces Health Surveillance Branch. Standardized chart reviews were performed to provide a gold standard by which to validate the case definition algorithm. In a cohort of active component U.S. Air Force, Navy, and Marine Corps officers followed from 1 October 1995 through 31 December 2017, a total of 2,422 individuals contributed 3,104 algorithm-derived cancer cases. Of these cases, 2,108 (67.9%) were classified as confirmed cancers, 568 (18.3%) as confirmed not cancers, and 428 (13.8%) as unclear. The overall positive predictive value (PPV) of the algorithm was 78.8% (95% confidence interval [CI]: 77.2-80.3). For the 12 cancer sites with at least 50 cases identified by the algorithm, the PPV ranged from a high of 99.6% for breast and testicular cancers (95% CI: 97.8-100.0 and 97.7-100.0, respectively) to a low of 78.1% (95% CI: 71.3-83.9) for non-Hodgkin lymphoma. Of the 568 cases confirmed as not cancer, 527 (92.7%) occurred in individuals with at least 1 other confirmed cancer, suggesting algorithmic capture of metastases as additional primary cancers.

Factors That Contributed to Black-White Disparities in Survival Among Nonelderly Women With Breast Cancer Between 2004 and 2013

Purpose

To estimate the contribution of differences in demographics, comorbidity, insurance, tumor characteristics, and treatment to the overall mortality disparity between nonelderly black and white women diagnosed with early-stage breast cancer.

Patients and Methods

Excess relative risk of all-cause death in black versus white women diagnosed with stage I to III breast cancer, expressed as a percentage and stratified by hormone receptor status for each variable (demographics, comorbidity, insurance, tumor characteristics, and treatment) in sequentially, propensity-scored, optimally matched patients by using multivariable hazard ratios (HRs).

Results

We identified 563,497 white and black women 18 to 64 years of age diagnosed with stage I to III breast cancer from 2004 to 2013 in the National Cancer Data Base. Among women with hormone receptor–positive disease, who represented 78.5% of all patients, the HR for death in black versus white women in the demographics-matched model was 2.05 (95% CI, 1.94 to 2.17). The HR decreased to 1.93 (95% CI, 1.83 to 2.04), 1.54 (95% CI, 1.47 to 1.62), 1.30 (95% CI, 1.24 to 1.36), and 1.25 (95% CI, 1.19 to 1.31) when sequentially matched for comorbidity, insurance, tumor characteristics, and treatment, respectively. These factors combined accounted for 76.3% of the total excess risk of death in black patients; insurance accounted for 37.0% of the total excess, followed by tumor characteristics (23.2%), comorbidities (11.3%), and treatment (4.8%). Results generally were similar among women with hormone receptor–negative disease, although the HRs were substantially smaller.

Conclusion

Matching by insurance explained one third of the excess risk of death among nonelderly black versus white women diagnosed with early-stage breast cancer; matching by tumor characteristics explained approximately one fifth of the excess risk. Efforts to focus on equalization of access to care could substantially reduce ethnic/racial disparities in overall survival among nonelderly women diagnosed with breast cancer.

Cancer treatment and survivorship statistics, 2014

The number of cancer survivors continues to increase due to the aging and growth of the population and improvements in early detection and treatment. In order for the public health community to better serve these survivors, the American Cancer Society and the National Cancer Institute collaborated to estimate the number of current and future cancer survivors using data from the Surveillance, Epidemiology, and End Results (SEER) program registries. In addition, current treatment patterns for the most common cancer types are described based on information in the National Cancer Data Base and the SEER and SEER-Medicare linked databases; treatment-related side effects are also briefly described. Nearly 14.5 million Americans with a history of cancer were alive on January 1, 2014; by January 1, 2024, that number will increase to nearly 19 million. The 3 most common prevalent cancers among males are prostate cancer (43%), colorectal cancer (9%), and melanoma (8%), and those among females are cancers of the breast (41%), uterine corpus (8%), and colon and rectum (8%). The age distribution of survivors varies substantially by cancer type. For example, the majority of prostate cancer survivors (62%) are aged 70 years or older, whereas less than one-third (32%) of melanoma survivors are in this older age group. It is important for clinicians to understand the unique medical and psychosocial needs of cancer survivors and to proactively assess and manage these issues. There are a growing number of resources that can assist patients, caregivers, and health care providers in navigating the various phases of cancer survivorship.

Disparities in survival improvement for metastatic colorectal cancer by race/ethnicity and age in the United States

PURPOSE

Previous studies documented significant increase in overall survival for metastatic colorectal cancer (CRC) since the late 1990s coinciding with the introduction and dissemination of new treatments. We examined whether this survival increase differed across major racial/ethnic populations and age groups.

METHODS

We identified patients diagnosed with primary metastatic colorectal cancer during 1992-2009 from 13 population-based cancer registries of the National Cancer Institute's Surveillance, Epidemiology, and End Results Program, which cover about 14 % of the US population. The 5-year cause-specific survival rates were calculated using SEER*Stat software.

RESULTS

From 1992-1997 to 2004-2009, 5-year cause-specific survival rates increased significantly from 9.8 % (95 % CI 9.2-10.4) to 15.7 % (95 % CI 14.7-16.6) in non-Hispanic whites and from 11.4 % (95 % CI 9.4-13.6) to 17.7 % (95 % CI 15.1-20.5) in non-Hispanic Asians, but not in non-Hispanic blacks [from 8.6 % (95 % CI 7.2-10.1) to 9.8 % (95 % CI 8.1-11.8)] or Hispanics [from 14.0 % (95 % CI 11.8-16.3) to 16.4 % (95 % CI 14.0-19.0)]. By age group, survival rates increased significantly for the 20-64-year age group and 65 years or older age group in non-Hispanic whites, although the improvement in the older non-Hispanic whites was substantially smaller. Rates also increased in non-Hispanic Asians for the 20-64-year age group although marginally nonsignificant. In contrast, survival rates did not show significant increases in both younger and older age groups in non-Hispanic blacks and Hispanics.

CONCLUSION

Non-Hispanic blacks, Hispanics, and older patients diagnosed with metastatic CRC have not equally benefitted from the introduction and dissemination of new treatments.

Abstract PL08-02: Colorectal cancer health disparities: Role of racial disparities in stage

Colorectal cancer (CRC) is the second leading cause of cancer death in the US. Over the last four decades, advances in screening, early detection, and treatment have led to large reductions in age-adjusted CRC mortality rates. However, as the overall CRC mortality rate has declined, disparities in CRC mortality have worsened. For example, using data from the nine original registries in the Surveillance, Epidemiology, and End Results Program (denoted as SEER 9), in 1975–79, age-adjusted CRC mortality rates for whites and blacks were 29.0 and 29.7 per 100,000, respectively. However, during 2005–09, the corresponding rates were 15.1 and 23.1, respectively (53.0% higher rate in blacks). (All incidence and mortality rates in this presentation are per 100,000 population and age-adjusted to the 2000 US Standard Population. Stage at diagnosis was grouped into local, regional, distant, and unstaged, according to SEER Summary Stage guidelines.)

Cancer mortality rates are driven by trends in stage-specific incidence rates and stage-specific survival. Because of the poorer survival for advanced disease, decreases in the incidence of regional and distant stage, and increases in survival for advanced disease have particularly favorable impacts on the mortality rate. Overall and stage-specific incidence rates are affected by changes in risk factor prevalence as well as screening and early detection programs, while stage-specific survival rates are primarily affected by improvements in treatment.

This presentation describes trends for whites and blacks in the US from 1975 to 2009, using data from SEER 9, which covers approximately 10% of the US population. Race-specific trend data are presented for CRC mortality, incidence, and 5-year relative survival rates (relative survival is the ratio of observed to expected survival and represents the probability of surviving cancer for a specific period of time).

Between 1975–79 and 2005–09, for whites, overall CRC incidence decreased from 62.3 to 44.4 (–28.7%), while for blacks, overall incidence only decreased from 58.7 to 55.5 (–5.5%). For whites, stage-specific changes in incidence during this time were as follows: localized, from 20.9 to 19.0 (–9.1%); regional, from 22.2 to 15.1 (–32.0%); distant, from 12.9 to 8.3 (–35.7%); and unstaged, from 6.2 to 2.0 (–67.7%). For blacks, corresponding stage-specific incidence changes were: localized, from 17.9 to 21.9 (+22.3%); regional, from 19.5 to 17.0 (–12.8%); distant, from 14.8 to 13.1 (–11.5%); and unstaged, from 6.4 to 3.6 (–43.8%).

Changes in stage-specific 5-year relative survival were also examined, using data from CRC cases diagnosed during 1975–77 and cases diagnosed during 2002–08; all cases were followed through December 2009. For whites, the changes in stage-specific survival were as follows: localized, from 82.2% to 91.1% (+10.8%); regional, from 53.8% to 72.2% (+34.2%); distant, from 5.6 % to 12.6% (+125.0%); and unstaged, from 31.3 % to 28.9% (+%). For blacks, corresponding changes in survival were: localized, from 76.5% to 85.9% (+12.3%); regional, from 50.0% to 65.4% (+30.8%); distant, from 6.3% to 8.3% (+31.7%); and unstaged, from 34.9% to 32.6% (6.6%).

These data suggest that both decreases in stage-specific incidence and increases in stage-specific survival have played important roles in the downward trend in CRC mortality rates, particularly for whites. With respect to stage-specific incidence, whites experienced much larger decreases in the incidence of advanced (regional and distant) disease, particularly distant stage. As noted above, 5-year survival for distant stage is very poor (from SEER-9, 13% for whites and 8% for blacks in the most recent time period). Whites also experienced larger increases in stage-specific survival, particularly for distant stage, where their survival more than doubled over this four-decade period.

These data suggest that advances in screening, early detection, and treatment of CRC have not equally benefitted whites and blacks, and that these inequities have contributed to worsening racial disparities in CRC mortality.

Citation Format: Anthony S. Robbins. Colorectal cancer health disparities: Role of racial disparities in stage. [abstract]. In: Proceedings of the Fifth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2012 Oct 27-30; San Diego, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2012;21(10 Suppl):Abstract nr PL08-02.

Ask the Experts: Race and colorectal cancer survival

Anthony S Robbins speaks to Ruth Williamson, Commissioning Editor: Dr Robbins received a BS in Biochemistry from the University of California, a MD from the University of Southern California School of Medicine, a MPH in Epidemiology from Loma Linda University and a PhD in Epidemiology from Stanford University. While at Stanford he also completed a fellowship in Health Services Research. He served for 13 years on active duty as a medical officer in the US Air Force, spending much of that time directing and conducting both observational and interventional epidemiologic research studies. In 2005, Dr Robbins separated from active military service and joined the California Cancer Registry, where he spent 2 years as a regional cancer epidemiologist responsible for cancer surveillance and cluster investigation for a 16-county region covering much of northern California. During this time Dr Robbins also used statewide California Cancer Registry data to conduct numerous epidemiologic studies examining racial/ethnic differences in cancer treatment and survival, as well as the relationship between county-level changes in breast cancer incidence and the use of hormone therapy in California. He joined the Research Department at the American Cancer Society in 2008 as Director of Health Services Research. Dr Robbins’ research in the areas of cancer epidemiology and health services research has focused on cancer health disparities; specifically, geographic and racial/ethnic differences in cancer incidence and mortality, and racial/ethnic differences in cancer survival and cancer treatment. The goal of his research is to move from why cancer health disparities occur to how they can be prevented. Dr Robbins also serves on a number of committees and workgroups of the American College of Surgeons Commission on Cancer.

Racial disparities in stage-specific colorectal cancer mortality rates from 1985 to 2008

PURPOSE

Since the early 1980s, colorectal cancer (CRC) mortality rates for whites and blacks in the United States have been diverging as a result of earlier and larger reductions in death rates for whites. We examined whether this mortality pattern varies by stage at diagnosis.

METHODS

The Incidence-Based Mortality database of the Surveillance, Epidemiology, and End Results (SEER) Program was used to examine data from the nine original SEER regions. Our main outcome measures were changes in stage-specific mortality rates by race.

RESULTS

From 1985 to 1987 to 2006 to 2008, CRC mortality rates decreased for each stage in both blacks and whites, but for every stage, the decreases were smaller for blacks, particularly for distant-stage disease. For localized stage, mortality rates decreased 30.3% in whites compared with 13.2% in blacks; for regional stage, declines were 48.5% in whites compared with 34.0% in blacks; and for distant stage, declines were 32.6% in whites compared with 4.6% in blacks. As a result, the black-white rate ratios increased from 1.17 (95% CI, 0.98 to 1.39) to 1.41 (95% CI, 1.21 to 1.63) for localized disease, from 1.03 (95% CI, 0.93 to 1.14) to 1.30 (95% CI, 1.17 to 1.44) for regional disease, and from 1.21 (95% CI, 1.10 to 1.34) to 1.72 (95% CI, 1.58 to 1.86) for distant-stage disease. In absolute terms, the disparity in distant-stage mortality rates accounted for approximately 60% of the overall black-white mortality disparity.

CONCLUSION

The black-white disparities in CRC mortality increased for each stage of the disease, but the overall disparity in overall mortality was largely driven by trends for late-stage disease. Concerted efforts to prevent or detect CRC at earlier stages in blacks could improve the worsening black- white disparities.

Persistent disparities in liver transplantation for patients with hepatocellular carcinoma in the United States, 1998 through 2007

BACKGROUND

Prior studies have demonstrated that among patients with hepatocellular carcinoma (HCC), African Americans (AAs) and Asian/Pacific Islanders (APIs) are substantially less likely to undergo liver transplantation (LT) compared with whites. The authors examined whether disparities in the receipt of LT among LT-eligible HCC patients changed over a 10-year time period, and whether the disparities might be explained by sociodemographic or clinical factors.

METHODS

The National Cancer Data Base, a national hospital-based cancer registry, was used to study 7707 adults with small (≤ 5 cm), nonmetastatic HCC diagnosed between 1998 and 2007. Racial/ethnic patterns in the use of LT were compared during 2 periods of 5 years each: 1998 through 2002 (n = 2412 patients) and 2003 through 2007 (n = 5295 patients). Data regarding comorbid medical conditions were only available during the later time period.

RESULTS

Large and persistent racial/ethnic differences in the probability of receiving LT were observed. Compared with whites, hazard ratios (HRs) and associated 95% confidence intervals (95% CIs) for receiving LT from 1998 through 2002 were 0.64 (95% CI, 0.46-0.89) for AA patients, 1.01 (95% CI, 0.79-1.29) for Hispanic patients, and 0.52 (95% CI, 0.39-0.68) for API patients. Analogous results for 2003 through 2007 were 0.64 (95% CI, 0.54-0.76) for AA patients, 0.86 (95% CI, 0.75-0.99) for Hispanic patients, and 0.58 (95% CI, 0.49-0.69) for API patients. AA patients were less likely than whites to undergo any form of surgery, and API patients were more likely than whites to undergo surgical resection. Adjustment for sociodemographic and clinical factors produced only small changes in these HRs.

CONCLUSIONS

Between 1998 and 2007, there were large and persistent racial/ethnic disparities noted in the receipt of LT among patients with HCC. These disparities were not explained by sociodemographic or clinical factors.

Insurance status and survival disparities among nonelderly rectal cancer patients in the National Cancer Data Base

BACKGROUND

Among patients with colorectal cancer, insurance status is associated with disparities in survival as well as differences in stage and treatment. The role of stage and treatment differences in these survival disparities is not clear because insurance status is also strongly correlated with race/ethnicity, socioeconomic status, and other factors.

METHODS

The authors used data from the National Cancer Data Base, a national hospital-based cancer registry, to examine insurance status and other factors related to survival among 19,154 rectal cancer patients aged 18 to 64 years. The authors examined the impact of 10 factors on 5-year survival: age, sex, race/ethnicity, histologic grade, histologic subtype, neighborhood education and income levels, facility type, stage, and treatment.

RESULTS

Adjusted only for age, the hazard ratio (HR) for death at 5 years was 1.00 (referent) among privately insured patients, 2.05 (95% confidence interval [CI], 1.89-2.23) among Medicaid-insured patients, and 2.01 (95% CI, 1.84-2.19) among uninsured patients. After adjustment for all factors other than stage and treatment, the HRs were 1.88 (95% CI, 1.722.04) for Medicaid-insured patients and 1.84 (95% CI, 1.69-2.01) for uninsured patients. After further adjustment for stage and treatment, the HRs were 1.34 (95% CI, 1.22-1.46) for Medicaid-insured patients and 1.29 (95% CI, 1.18-1.42) for uninsured patients.

CONCLUSIONS

After adjustment for age, further adjustment for 9 other factors reduced the excess mortality among rectal cancer patients without private insurance by approximately 70%. Disparities in stage and treatment accounted for approximately 53% of the excess mortality, whereas factors other than stage and treatment accounted for approximately 17%.

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

PURPOSE

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

METHODS

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

Decreasing disparity in liver transplantation among white and Asian patients with hepatocellular carcinoma : California, 1998-2005

BACKGROUND

A preliminary study using national cancer surveillance data from 1998 through 2002 suggested that there were significant differences between non-Hispanic whites ('whites') and Asian/Pacific Islanders (APIs) in the use of liver transplantation as a treatment for hepatocellular carcinoma (HCC).

METHODS

The objective of the current study was to examine whether differences in liver transplantation between whites and APIs with HCC were changing over time. By using a population-based, statewide cancer registry, data were obtained on all HCC cases diagnosed in California between 1998 and 2005, and the study was limited to white and API patients with nonmetastatic HCC who had tumors that measured < or = 5 cm in greatest dimension (n = 1728 patients).

RESULTS

From 1998 through 2003 (n = 1051 patients), the odds of undergoing liver transplantation were 2.56 times greater for white patients than for API patients (95% confidence interval [CI], 1.72-3.80 times higher), even after adjusting for age, sex, marital status, year of diagnosis, TNM stage, and tumor grade. In contrast, during 2004 and 2005 (n = 677 patients), there were no significant differences in the odds of undergoing liver transplantation. Between 2002 and 2004, changes in liver transplantation policy assigned priority points to patients with HCC (initially to stage I and II, then to stage II only). After the policy changes, API patients with HCC experienced a significant increase in stage II diagnoses, whereas white patients did not.

CONCLUSIONS

In California, there was a large and significant disparity in the rate of liver transplantation among white and API patients with HCC from 1998 through 2003 but not during 2004 and 2005. Changes in liver transplantation policy from 2002 through 2004 may have played a role in decreasing this difference.

Racial and ethnic differences in treatment and survival among adults with primary extremity soft-tissue sarcoma

BACKGROUND

Limb preservation is preferred to amputation for patients with extremity soft tissue sarcoma (ESTS). Disparities in the treatment and outcomes of several malignancies have been reported, but not for ESTS. The authors assessed racial/ethnic differences in patient- and tumor-specific characteristics, treatment, and disease-specific survival in a population of adults with ESTS.

METHODS

The Surveillance, Epidemiology, and End Results (SEER) database was used to identify 6406 adult patients with ESTS who were diagnosed and treated between 1988 and 2003. Patients were categorized into 1 of 4 racial/ethnic groups: whites, blacks, Hispanics, and Asians. Comparisons of treatment and disease-specific survival were conducted with regression models that adjusted for patient age, sex, SEER geographic region, extent of disease, tumor grade, tumor size, and histology.

RESULTS

Relative to whites, blacks received lower rates of adjuvant radiation with surgery (odds ratio [OR], 0.77; 95% confidence interval [95% CI], 0.66-0.90). Hispanics received significantly lower rates of limb-sparing surgery (OR, 0.76; 95% CI, 0.59-0.97). In a multivariate analysis controlling for patient age, sex, SEER geographic region, extent of disease, tumor grade, tumor size, and histology, blacks displayed a worse disease-specific survival (hazard ratio [HR] 1.39; 95% CI, 1.13-1.70), whereas Asians demonstrated superior disease-specific survival (HR, 0.67; 95% CI, 0.46-0.97).

CONCLUSIONS

There were significant racial/ethnic differences in treatment and survival among adults with ESTS. Compared with whites, survival was poorer for blacks but better for Asians. These disparities were not explained by differences in patient or tumor characteristics.

Differences in prognostic factors and survival among white and Asian men with prostate cancer, California, 1995-2004

BACKGROUND

There are very limited data concerning survival from prostate cancer among Asian subgroups living in the U.S., a large proportion of whom reside in California. There do not appear to be any published data on prostate cancer survival for the more recently immigrated Asian subgroups (Korean, South Asian [SA], and Vietnamese).

METHODS

A study of prognostic factors and survival from prostate cancer was conducted in non-Hispanic whites and 6 Asian subgroups (Chinese, Filipino, Japanese, Korean, SA, and Vietnamese), using data from all men in California diagnosed with incident prostate cancer during 1995-2004 and followed through 2004 (n = 116,916). Survival was analyzed using Cox proportional hazards models.

RESULTS

Whites and Asians demonstrated significant racial differences in all prognostic factors: age, summary stage, primary treatment, histologic grade, socioeconomic status, and year of diagnosis. Every Asian subgroup had a risk factor profile that put them at a survival disadvantage compared with whites. Overall, the 10-year risk of death from prostate cancer was 11.9%. However, in unadjusted analyses Japanese men had significantly better survival than whites; Chinese, Filipino, Korean, and Vietnamese men had statistically equal survival; and SA men had significantly lower survival. On multivariate analyses adjusting for all prognostic factors, all subgroups except SA and Vietnamese men had significantly better survival than whites; the latter 2 groups had statistically equal survival.

CONCLUSIONS

Traditional prognostic factors for survival from prostate cancer do not explain why most Asian men have better survival compared with whites, but they do explain the poorer survival of SA men compared with whites.

Regional Changes in Hormone Therapy Use and Breast Cancer Incidence in California From 2001 to 2004

Purpose

Recently, an unprecedented 1-year 7% decrease in the overall incidence of invasive female breast cancer in the United States was reported. It has been suggested that the decrease resulted from the mass cessation of estrogen-progestin hormone therapy (EPHT) in 2002. We took advantage of California's unique population-based cancer surveillance resources to assess whether regional changes in breast cancer incidence observed between 2001 and 2004 correlated with regional changes in EPHT use between 2001 and 2003.

Methods

We obtained statewide cancer registry and California Health Interview Survey (CHIS) EPHT data for almost 3 million non-Hispanic white women age 45 to 74 years, residing in California's 58 counties. We examined trends in the age-adjusted incidence of invasive female breast cancer and compared these with trends in the use of EPHT, after grouping all California counties into three groups based on EPHT use in 2001. We also examined CHIS data on trends in screening mammography.

Results

In 2001, there were large regional differences in EPHT use and breast cancer incidence. From 2001 to 2004, incidence declined by 8.8% in the counties with the smallest EPHT reductions, by 13.9% in those with intermediate reductions, and by 22.6% in counties with the largest EPHT reductions. Between 2001 and 2003, CHIS data did not show any significant change in the proportion of women who reported having a mammogram in the previous 2 years.

Conclusion

These data support the hypothesis that changes in EPHT use in 2002 may be responsible for significant declines in breast cancer incidence between 2002 and 2003 and sustained through 2004.

Differences in prognostic factors and survival among White men and Black men with prostate cancer, California, 1995-2004

The authors conducted a study to determine whether differences in prostate cancer survival between White men and Black men are reduced or eliminated after accounting for differences in prognostic factors. Using population-based statewide cancer registry data, the authors analyzed data from a cohort of 122,375 non-Hispanic White men and Black men from California who were newly diagnosed with prostate cancer between 1995 and 2004 and followed through 2004. Compared with White men, Black men were characterized by younger age at diagnosis, more distant stage, less treatment with surgery or radiation therapy, higher tumor grades, lower neighborhood socioeconomic status, and more recent year of diagnosis. Adjusted only for age, the hazard ratio for prostate cancer death (Blacks vs. Whites) was 1.61 (95% confidence interval (CI): 1.50, 1.72). Additional adjustment for potentially modifiable factors (stage and treatment) eliminated most of the racial difference in survival (adjusted hazard ratio = 1.10, 95% CI: 1.03, 1.18). The racial difference in survival was completely eliminated after further adjustment for other factors (grade, socioeconomic status, and year of diagnosis) (adjusted hazard ratio = 0.99, 95% CI: 0.92, 1.06). Thus, the large difference in prostate cancer survival between White men and Black men was completely explained by known prognostic factors, with potentially modifiable disparities playing the largest role.

A Low-Intensity Intervention to Prevent Annual Weight Gain in Active Duty Air Force Members

Elevated body weight among active duty Air Force (ADAF) members is a substantial and growing problem, and typically results from gaining small amounts of weight each year over many years. We designed a strategy to prevent annual weight gain in ADAF members using self-directed behavior change booklets followed by weekly e-mails about diet and physical activity for a year. The intervention was universally offered to ADAF members meeting selection criteria at five U.S. Air Force bases (n = 3,502); members at 60 other U.S. Air Force bases served as controls (n = 65,089). The intervention was completely effective at preventing weight gain in a subgroup of men (those above the lowest three ranks, with baseline weight above maximum allowable) and in women, while controls continued to gain weight. Since the intervention did not require personalized contact, this approach has promise for large-scale population-based efforts aimed at preventing weight gain in working adults.

An Intervention to Reduce Excess Body Weight in Adults with or at Risk for Type 2 Diabetes

Overweight and obesity increase risk for type 2 diabetes, which, in turn, increases the risk of cardiovascular disease (CVD); therefore, effective interventions to control body weight have the potential to prevent many cases of diabetes and CVD in the United States. However, few randomized controlled trials have shown that behavioral interventions can control body weight in persons with diabetes or at risk for diabetes. Therefore, the authors conducted a clinic-based randomized controlled trial, testing whether a comprehensive behavioral intervention could reduce weight, total cholesterol, and blood pressure (BP) in persons with two or more risk factors for diabetes and/or CVD. Approximately 50% of the participants had diabetes at baseline. Intervention participants had significantly greater reductions in weight and systolic BP than control participants, who received usual care. Among participants with nonelevated baseline values of total cholesterol and diastolic BP, intervention participants also had significantly greater reductions in these risk factors.

Unplanned Pregnancy among Active Duty Servicewomen, U.S. Air Force, 2001

Unplanned pregnancy is a major public health problem in the United States. Although the U.S. Air Force has the highest proportion of active duty women of any of the U.S. military services, there are no published data on the occurrence of unplanned pregnancy among active duty Air Force (ADAF) women. Civilian female interviewers conducted telephone interviews with a random sample of 2,348 ADAF women during early 2002, using questions that were closely based on the 1995 National Survey of Family Growth. During 2001, approximately 12% of ADAF women had one or more pregnancies. By National Survey of Family Growth criteria, approximately 54% of these pregnancies were unplanned. Thus, approximately 7% of ADAF women had one or more unplanned pregnancies during 2001. Roughly one-half of unplanned pregnancies represented contraceptive nonuse and the other half represented contraceptive failure or misuse. Unplanned pregnancy is a serious and frequently occurring problem among ADAF women, with many opportunities for prevention.

One-year costs of increased screening and treatment for breast cancer in the Air Force Medical Service

The Air Force Medical Service is attempting to increase the screening mammography rate among women enrolled to U.S. Air Force military treatment facilities from 72% to 86% (a 20% relative increase). A study was performed to estimate the costs (from testing and first-year treatment) of this targeted increase. We estimated additional 1-year costs using two approaches referred to as the Primary Care Optimization (PCO) approach and the TRICARE Prime benefit (TPB) approach. Under the PCO approach, women ages > or = 50 years are screened every 2 years, whereas under the TPB approach, women are screened every 2 years from ages 40 to 49 years and annually beginning at age 50 years. As of December 31, 2000, 68,360 women ages 40 to 49 years and 70,563 women ages 50 to 69 years were enrolled to U.S. Air Force military treatment facilities. Additional 1-year costs (and additional cases detected by screening) were estimated at dollars 447,096 for the PCO approach (58 additional cases) and dollars 1,340,140 for the TPB approach (72 additional cases). Compared with the PCO approach, under the TPB approach, the 1-year costs of increased screening and treatment for breast cancer at U.S. Air Force military treatment facilities would be three times higher, but the number of additional cases detected by screening would be only 24% higher.

What's the relative risk? A method to directly estimate risk ratios in cohort studies of common outcomes

PURPOSE

In cohort studies of common outcomes, odds ratios (ORs) may seriously overestimate the true effect of an exposure on the outcome of interest (as measured by the risk ratio [RR]). Since few study designs require ORs (most frequently, case-control studies), their popularity is due to the widespread use of logistic regression. Because ORs are used to approximate RRs so frequently, methods have been published in the general medical literature describing how to convert ORs to RRs; however, these methods may produce inaccurate confidence intervals (CIs). The authors explore the use of binomial regression as an alternative technique to directly estimate RRs and associated CIs in cohort studies of common outcomes.

METHODS

Using actual study data, the authors describe how to perform binomial regression using the SAS System for Windows, a statistical analysis program widely used by US health researchers.

RESULTS

In a sample data set, the OR for the exposure of interest overestimated the RR more than twofold. The 95% CIs for the OR and converted RR were wider than for the directly estimated RR.

CONCLUSIONS

The authors argue that for cohort studies, the use of logistic regression should be sharply curtailed, and that instead, binomial regression be used to directly estimate RRs and associated CIs.

Costs of excess body weight among active duty personnel, U.S. Air Force, 1997

Although the increasing public health impact of excess body weight in the U.S. general population has received national attention, the impact of excess body weight among active duty military personnel is unknown. A study was conducted to determine the direct (increased medical care) and indirect (lost workdays) costs of excess body weight among active duty Air Force (ADAF) personnel in 1997. Based on measured height and weight values, in 1997, 20.4% of ADAF men and 20.5% of ADAF women had body weights that exceeded their official maximum allowable weight for height. Total excess body weight-attributable costs were estimated at $22.8 million per year, with annual direct and indirect costs estimated at $19.3 million (approximately 6% of total annual expenditures for ADAF medical care) and $3.5 million, respectively. Attributable lost workdays were estimated at 28,351 per year. Annual excess body weight-attributable costs among ADAF personnel are high, both in dollars and lost duty days.

Recent trends in workload, input costs, and expenditures in the Air Force Medical Service Direct Care System

A study was conducted to examine the relationship between two types of trends in the Air Force Medical Service Direct Care System (AFMS/DCS): trends in expenditures, total and by categories; and trends in medical workload, defined as the sum of inpatient admissions and outpatient clinic visits. Expenditure and medical workload data were extracted from the Medical Expense and Performance Reporting System Executive Query System. Medical inflation data were obtained from the Bureau of Labor Statistics Producer Price Index series. Between fiscal years 1995 and 1999, the AFMS/DCS experienced a 21.2% decrease in medical workload, but total (nominal) expenditures declined only 3.6%. Of all expenditure categories, only inpatient medical care, outpatient medical care, and military-funded private sector care for active duty personnel (supplemental care) have any direct relationship with AFMS/DCS medical workload. Real expenditures for the three categories above decreased by 20.3% during the 5-year period. Accounting for inflation and considering only expenditures related to medical workload, these results suggest that the AFMS/DCS is spending approximately 20% less money to do approximately 20% less work.

Weight gain as a barrier to smoking cessation among military personnel

PURPOSE

To assess the relationships between active-duty military status, military weight standards, concern about weight gain, and anticipated relapse after smoking cessation.

DESIGN

Cross-sectional study.

SETTING

Hospital-based tobacco cessation program.

SUBJECTS

Two hundred fifty-two enrollees, of 253 eligible, to a tobacco cessation program in 1999 (135 men, 117 women; 43% on active duty in the military).

MEASURES

Independent variables included gender, body mass index (weight/height2), and military status. Dependent variables included about weight gain with smoking cessation and anticipated relapse.

RESULTS

In multivariate regression analyses that controlled for gender and body mass index, active-duty military status was associated with an elevated level of concern about weight gain (1.9-point increase on a 10-point scale; 95% confidence interval [CI], 1.0- to 2.8-point increase), as well as higher anticipated relapse (odds ratio [OR] = 3.6; 95% CI, 1.3 to 9.8). Among subjects who were close to or over the U.S. Air Force maximum allowable weight for height, the analogous OR for active-duty military status was 6.9 (p = .02).

CONCLUSIONS

Occupational weight standards or expectations may pose additional barriers for individuals contemplating or attempting smoking cessation, as they do among active-duty military personnel. These barriers are likely to hinder efforts to decrease smoking prevalence in certain groups.

Predictors of low physical fitness in a cohort of active-duty U.S. Air Force members

BACKGROUND

Each branch of the U.S. armed forces has standards for physical fitness as well as programs for ensuring compliance with these standards. In the U.S. Air Force (USAF), physical fitness is assessed using submaximal cycle ergometry to estimate maximal oxygen uptake (VO2(max)). The purpose of this study was to identify the independent effects of demographic and behavioral factors on risk of failure to meet USAF fitness standards (hereafter called low fitness).

METHODS

A retrospective cohort study (N=38,837) was conducted using self-reported health risk assessment data and cycle ergometry data from active-duty Air Force (ADAF) members. Poisson regression techniques were used to estimate the associations between the factors studied and low fitness.

RESULTS

The factors studied had different effects depending on whether members passed or failed fitness testing in the previous year. All predictors had weaker effects among those with previous failure. Among those with a previous pass, demographic groups at increased risk were toward the upper end of the ADAF age distribution, senior enlisted men, and blacks. Overweight/obesity was the behavioral factor with the largest effect among men, with aerobic exercise frequency ranked second; among women, the order of these two factors was reversed. Cigarette smoking only had an adverse effect among men. For a hypothetical ADAF man who was sedentary, obese, and smoked, the results suggested that aggressive behavioral risk factor modification would produce a 77% relative decrease in risk of low fitness.

CONCLUSIONS

Among ADAF members, both demographic and behavioral factors play important roles in physical fitness. Behavioral risk factors are prevalent and potentially modifiable. These data suggest that, depending on a member's risk factor profile, behavioral risk factor modification may produce impressive reductions in risk of low fitness among ADAF personnel.