Frequency distributions of breast cancer characteristics classified by estrogen receptor and progesterone receptor status for eight racial/ethnic groups

BACKGROUND

The National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) cancer registries have been collecting data regarding estrogen receptor (ER) and progesterone receptor (PR) status in breast cancer since 1990. The current study reports on some of these data for eight racial/ethnic groups.

METHODS

Stratified by ER and PR status, the frequency distributions of 112,588 breast cancer cases diagnosed between 1992--1997 in 11 SEER cancer registries were examined by age at diagnosis, stage at diagnosis, histologic grade, and tumor type for white, black, Hispanic, Japanese, Chinese, Filipino, Native Hawaiian, and American Indian and Alaska Native (AI/AN) females.

RESULTS

For each racial/ethnic group, the percentage of ER positive (+)/PR+ was > ER-PR- > ER+PR- > ER-PR+ tumors. For the two major ER/PR groups, the ER+PR+ tumors were different from the ER-PR- tumors in several ways. For white females, there were differences in the age distributions, stage at diagnosis, and histologic grade. For black females, the differences involved the age distributions and tumor grades. For Hispanic and Japanese females, there were differences with regard to the age distributions and tumor grades. For Filipino, Chinese, and AI/AN females, the tumor stages and grades differed. For Native Hawaiians, the histologic tumor grades were different.

CONCLUSIONS

For each racial/ethnic group, the ER/PR status appeared to divide breast cancer patients into two or more subgroups with unique tumor characteristics. In general, ER status appeared to have the greatest impact on delineating these subgroups, whereas in some cases, PR status was able to modify the subgroups further. It is hoped that reporting these tumor characteristics by ER/PR status for each racial/ethnic group will spur more investigation into the significance of ER/PR status in each racial/ethnic group.

Annual report to the nation on the status of cancer (1973 through 1998), featuring cancers with recent increasing trends

BACKGROUND

The American Cancer Society, the National Cancer Institute (NCI), the North American Association of Central Cancer Registries, and the Centers for Disease Control and Prevention, including the National Center for Health Statistics (NCHS), collaborate to provide an annual update on cancer occurrence and trends in the United States. This year's report contains a special feature that focuses on cancers with recent increasing trends.

METHODS

From 1992 through 1998, age-adjusted rates and annual percent changes are calculated for cancer incidence and underlying cause of death with the use of NCI incidence and NCHS mortality data. Joinpoint analysis, a model of joined line segments, is used to examine long-term trends for the four most common cancers and for those cancers with recent increasing trends in incidence or mortality. Statistically significant findings are based on a P value of.05 by use of a two-sided test. State-specific incidence and death rates for 1994 through 1998 are reported for major cancers.

RESULTS

From 1992 through 1998, total cancer death rates declined in males and females, while cancer incidence rates declined only in males. Incidence rates in females increased slightly, largely because of breast cancer increases that occurred in some older age groups, possibly as a result of increased early detection. Female lung cancer mortality, a major cause of death in women, continued to increase but more slowly than in earlier years. In addition, the incidence or mortality rate increased in 10 other sites, accounting for about 13% of total cancer incidence and mortality in the United States.

CONCLUSIONS

Overall cancer incidence and death rates continued to decline in the United States. Future progress will require sustained improvements in cancer prevention, screening, and treatment.

Effect of age and comorbidity in postmenopausal breast cancer patients aged 55 years and older

CONTEXT

Postmenopausal women aged 55 years and older have 66% of incident breast tumors and experience 77% of breast cancer mortality, but other age-related health problems may affect tumor prognosis and treatment decisions.

OBJECTIVE

To document the comorbidity burden of postmenopausal breast cancer patients and evaluate its relationship with age on disease stage, treatment, and early mortality.

DESIGN AND SETTING

Data were collected on breast cancer patients' comorbidities by retrospective hospital medical records review and merged with information on patients' tumor characteristics collected from 6 regional National Cancer Institute Surveillance, Epidemiology, and End Results cancer registries. Patients were followed up until death or for 30 months from breast cancer diagnosis.

PARTICIPANTS

Population-based random sample of 1800 postmenopausal breast cancer patients diagnosed in 1992 stratified by 3 age groups: 55 to 64 years, 65 to 74 years, and 75 years and older.

MAIN OUTCOME MEASURES

Extent of disease, therapy received, comorbidity, cause of death, and survival.

RESULTS

Seventy-three percent (1312 of 1800) of the sample was diagnosed with stage I and II breast cancer, 10% (n = 188) with stage III and IV breast cancer, and 17% (n = 300) did not have a stage assignment. Of the 1017 patients with stage I and stage II node-negative breast cancer, 95% received therapy in agreement with the National Institutes of Health consensus statement recommendation for early-stage breast cancer. Patients in older age groups were less likely to receive therapy consistent with the consensus statement (P<.001), and women aged 70 years and older were significantly less likely to receive axillary lymph node dissection as determined by logistic regression analysis (P<.01). Diabetes, renal failure, stroke, liver disease, a previous malignant tumor, and smoking were significant in predicting early mortality in a statistical model that included age and disease stage. Breast cancer was the underlying cause of death for 135 decedents (51.3%). Heart disease (n = 45, 17.1%) and previous cancers (n = 22, 8.4%) were the next major underlying causes. In the 30-month follow-up period, 263 patients (15%) died.

CONCLUSION

Patient care decisions occur in the context of breast cancer and other age-related conditions. Comorbidity in older patients may limit the ability to obtain prognostic information (ie, axillary lymph node dissection), tends to minimize treatment options (eg, breast-conserving therapy), and increases the risk of death from causes other than breast cancer.

The annual report to the nation on the status of cancer, 1973-1997, with a special section on colorectal cancer

BACKGROUND

This annual report to the nation addresses progress in cancer prevention and control in the U.S. with a special section on colorectal cancer. This report is the joint effort of the American Cancer Society, the National Cancer Institute (NCI), the North American Association of Central Cancer Registries (NAACCR), and the Centers for Disease Control and Prevention (CDC), including the National Center for Health Statistics (NCHS).

METHODS

Age-adjusted rates were based on cancer incidence data from the NCI and NAACCR and underlying cause of death as compiled by NCHS. Joinpoint analysis was based on NCI Surveillance, Epidemiology, and End Results (SEER) program incidence rates and NCHS death rates for 1973-1997. The prevalence of screening examinations for colorectal cancer was obtained from the CDC's Behavioral Risk Factor Surveillance System and the NCHS's National Health Interview Survey.

RESULTS

Between 1990-1997, overall cancer incidence and death rates declined. Joinpoint analyses of cancer incidence and death rates confirmed the declines described in earlier reports. The incidence trends for colorectal cancer have shown recent steep declines for whites in contrast to a leveling off of the rates for blacks. State-to-state variations occurred in colorectal cancer screening prevalence as well as incidence and death rates.

CONCLUSIONS

The continuing declines in overall cancer incidence and death rates are encouraging. However, a few of the top ten incidence or mortality cancer sites continued to increase or remained level. For many cancer sites, whites had lower incidence and mortality rates than blacks but higher rates than Hispanics, Asian and Pacific Islanders, and American Indians/Alaska Natives. The variations in colorectal cancer incidence and death rates by race/ethnicity, gender, age, and geographic area may be related to differences in risk factors, demographic characteristics, screening, and medical practice. New efforts currently are underway to increase awareness of screening benefits and treatment for colorectal cancer.

The annual report to the nation on the status of cancer, 1973-1997, with a special section on colorectal cancer

BACKGROUND

This annual report to the nation addresses progress in cancer prevention and control in the U.S. with a special section on colorectal cancer. This report is the joint effort of the American Cancer Society, the National Cancer Institute (NCI), the North American Association of Central Cancer Registries (NAACCR), and the Centers for Disease Control and Prevention (CDC), including the National Center for Health Statistics (NCHS).

METHODS

Age-adjusted rates were based on cancer incidence data from the NCI and NAACCR and underlying cause of death as compiled by NCHS. Joinpoint analysis was based on NCI Surveillance, Epidemiology, and End Results (SEER) program incidence rates and NCHS death rates for 1973-1997. The prevalence of screening examinations for colorectal cancer was obtained from the CDC's Behavioral Risk Factor Surveillance System and the NCHS's National Health Interview Survey.

RESULTS

Between 1990-1997, overall cancer incidence and death rates declined. Joinpoint analyses of cancer incidence and death rates confirmed the declines described in earlier reports. The incidence trends for colorectal cancer have shown recent steep declines for whites in contrast to a leveling off of the rates for blacks. State-to-state variations occurred in colorectal cancer screening prevalence as well as incidence and death rates.

CONCLUSIONS

The continuing declines in overall cancer incidence and death rates are encouraging. However, a few of the top ten incidence or mortality cancer sites continued to increase or remained level. For many cancer sites, whites had lower incidence and mortality rates than blacks but higher rates than Hispanics, Asian and Pacific Islanders, and American Indians/Alaska Natives. The variations in colorectal cancer incidence and death rates by race/ethnicity, gender, age, and geographic area may be related to differences in risk factors, demographic characteristics, screening, and medical practice. New efforts currently are underway to increase awareness of screening benefits and treatment for colorectal cancer.

The annual report to the nation on the status of cancer, 1973-1997, with a special section on colorectal cancer

BACKGROUND

This annual report to the nation addresses progress in cancer prevention and control in the U.S. with a special section on colorectal cancer. This report is the joint effort of the American Cancer Society, the National Cancer Institute (NCI), the North American Association of Central Cancer Registries (NAACCR), and the Centers for Disease Control and Prevention (CDC), including the National Center for Health Statistics (NCHS).

METHODS

Age-adjusted rates were based on cancer incidence data from the NCI and NAACCR and underlying cause of death as compiled by NCHS. Joinpoint analysis was based on NCI Surveillance, Epidemiology, and End Results (SEER) program incidence rates and NCHS death rates for 1973-1997. The prevalence of screening examinations for colorectal cancer was obtained from the CDC's Behavioral Risk Factor Surveillance System and the NCHS's National Health Interview Survey.

RESULTS

Between 1990-1997, overall cancer incidence and death rates declined. Joinpoint analyses of cancer incidence and death rates confirmed the declines described in earlier reports. The incidence trends for colorectal cancer have shown recent steep declines for whites in contrast to a leveling off of the rates for blacks. State-to-state variations occurred in colorectal cancer screening prevalence as well as incidence and death rates.

CONCLUSIONS

The continuing declines in overall cancer incidence and death rates are encouraging. However, a few of the top ten incidence or mortality cancer sites continued to increase or remained level. For many cancer sites, whites had lower incidence and mortality rates than blacks but higher rates than Hispanics, Asian and Pacific Islanders, and American Indians/Alaska Natives. The variations in colorectal cancer incidence and death rates by race/ethnicity, gender, age, and geographic area may be related to differences in risk factors, demographic characteristics, screening, and medical practice. New efforts currently are underway to increase awareness of screening benefits and treatment for colorectal cancer.

Aging and cancer in America. Demographic and epidemiologic perspectives

It has been stated in this article and elsewhere that cancer patients aged 65 years and older deserve special attention as a target group for research efforts across the cancer-control spectrum. The available data show that the vulnerability of older persons to cancer is unmistakable. Clinicians will be treating more older patients as the nation ages. The future needs of this segment of the population must be anticipated. In this context, the following generic treatment questions are pertinent. What are the peculiarities of the aged host of which clinicians must be aware in evaluating the older cancer patient? Do various forms of cancer present differently in the elderly? How can be complications caused by the multiple pathologies inherent in the older patient be anticipated? What are the potential hazards and limitations of surgery, radiotherapy, and chemotherapy for older persons with cancer? What is known regarding increased risk of adverse reactions to medications, drugs, and interaction of drugs in older patients? The surveillance data and population estimates and projections presented in this article illustrate the extent of the problems of cancer in the elderly at the macro level. For the individual patient, the special knowledge of aging individuals and their health status based on geriatric medicine and gerontology that has been accumulating for the past several decades needs to be incorporated into the oncology armamentarium that has developed during the same period. The information and expertise from both fields must converge, and new knowledge must be developed at the aging/cancer interface and applied for the optimal treatment of cancer in the elderly.

Partitioning linear trends in age-adjusted rates

OBJECTIVE

Surveillance of chronic diseases includes monitoring trends in age-adjusted rates in the general population. Statistics that are calculated to describe and compare trends include the annual percent change and the percent change for a specified time period. However, it is also of interest to determine the contribution specific diseases make to an overall trend in order to better understand the impact of interventions and changes in the prevalence of risk factors. The objective here is to provide a method for partitioning a linear trend in age-adjusted rates into disease-specific components.

METHODS

The method presented is based on linear regression. The decreasing trend in age-adjusted cancer mortality rates for the total United States during the period 1991-96 is analyzed to illustrate the method.

RESULTS

Trends in mortality for cancers of the colon/rectum, breast, lung/bronchus, and prostate are found to be responsible for 75% of the decreasing trend in cancer mortality.

CONCLUSIONS

It is possible to partition an overall trend in age-adjusted rates under the assumption that it and the trends for all mutually exclusive and exhaustive subgroups of interest are linear.

Cancer surveillance series [corrected]: brain and other central nervous system cancers: recent trends in incidence and mortality

BACKGROUND

During the 1980s, the incidence of primary malignant brain and other central nervous system tumors (hereafter called brain cancer) was reported to be increasing among all age groups in the United States, while mortality was declining for persons younger than 65 years. We analyzed these data to provide updates on incidence and mortality trends for brain cancer in the United States and to examine these patterns in search of their causes.

METHODS

Data on incidence, overall and according to histology and anatomic site, and on relative survival were obtained from the Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute for 1975 through 1995. Mortality data were obtained from the National Center for Health Statistics. Medicare procedure claims from the National Cancer Institute's SEER-Medicare database were used for imaging trends. Statistically significant changes in incidence trends were identified, and annual percent changes were computed for log linear models.

RESULTS/CONCLUSIONS

Rates stabilized for all age groups during the most recent period for which SEER data were available, except for the group containing individuals 85 years of age or older. Mortality trends continued to decline for the younger age groups, and the steep increases in mortality seen in the past for the elderly slowed substantially. Patterns differed by age group according to the site and grade of tumors between younger and older patients. During the last decade, use of computed tomography scans was relatively stable for those 65-74 years old but increased among those 85 years old or older.

IMPLICATIONS

Improvements in diagnosis and changes in the diagnosis and treatment of elderly patients provide likely explanations for the observed patterns in brain cancer trends.

Cancer surveillance series: recent trends in childhood cancer incidence and mortality in the United States

BACKGROUND

Public concern about possible increases in childhood cancer incidence in the United States led us to examine recent incidence and mortality patterns.

METHODS

Cancers diagnosed in 14540 children under age 15 years from 1975 through 1995 and reported to nine population-based registries in the National Cancer Institute's Surveillance, Epidemiology, and End Results Program were investigated. Age-adjusted incidence was analyzed according to anatomic site and histologic categories of the International Classification of Childhood Cancer. Age-adjusted U.S. mortality rates were calculated. Trends in rates were evaluated by use of standard regression methods.

RESULTS

A modest rise in the incidence of leukemia, the most common childhood cancer, was largely due to an abrupt increase from 1983 to 1984; rates have decreased slightly since 1989. For brain and other central nervous system (CNS) cancers, incidence rose modestly, although statistically significantly (two-sided P = .020), largely from 1983 through 1986. A few rare childhood cancers demonstrated upward trends (e.g., the 40% of skin cancers designated as dermatofibrosarcomas, adrenal neuroblastomas, and retinoblastomas, the latter two in infants only). In contrast, incidence decreased modestly but statistically significantly for Hodgkin's disease (two-sided P = .037). Mortality rates declined steadily for all major childhood cancer categories, although less rapidly for brain/CNS cancers.

CONCLUSIONS

There was no substantial change in incidence for the major pediatric cancers, and rates have remained relatively stable since the mid-1980s. The modest increases that were observed for brain/CNS cancers, leukemia, and infant neuroblastoma were confined to the mid-1980s. The patterns suggest that the increases likely reflected diagnostic improvements or reporting changes. Dramatic declines in childhood cancer mortality represent treatment-related improvements in survival.

Cancer surveillance series: interpreting trends in prostate cancer--part I: Evidence of the effects of screening in recent prostate cancer incidence, mortality, and survival rates

BACKGROUND

The prostate-specific antigen test was approved by the U.S. Food and Drug Administration in 1986 to monitor the disease status in patients with prostate cancer and, in 1994, to aid in prostate cancer detection. However, after 1986, the test was performed on many men who had not been previously diagnosed with prostate cancer, apparently resulting in the diagnosis of a substantial number of early tumors. Our purpose is to provide insight into the effect of screening on prostate cancer rates. Detailed data are presented for whites because the size of the population allows for calculating statistically reliable rates; however, similar overall trends are seen for African-Americans and other races.

METHODS

Prostate cancer incidence data from the National Cancer Institute's Surveillance, Epidemiology, and End Results Program and mortality data from the National Center for Health Statistics were analyzed.

RESULTS/CONCLUSIONS

The following findings are consistent with a screening effect: 1) the recent decrease since 1991 in the incidence of distant stage disease, after not having been perturbed by screening; 2) the decline in the incidence of earlier stage disease beginning the following year (i.e., 1992); 3) the recent increases and decreases in prostate cancer incidence and mortality by age that appear to indicate a calendar period effect; and 4) trends in the incidence of distant stage disease by tumor grade and trends in the survival of patients with distant stage disease by calendar year that provide suggestive evidence of the tendency of screening to detect slower growing tumors.

IMPLICATIONS

The decline in the incidence of distant stage disease holds the promise that testing for prostate-specific antigen may lead to a sustained decline in prostate cancer mortality. However, population data are complex, and it is difficult to confidently attribute relatively small changes in mortality to any one cause.

Annual report to the nation on the status of cancer, 1973-1996, with a special section on lung cancer and tobacco smoking

BACKGROUND

The American Cancer Society, the National Cancer Institute (NCI), and the Centers for Disease Control and Prevention (CDC), including the National Center for Health Statistics (NCHS), provide the second annual report to the nation on progress in cancer prevention and control, with a special section on lung cancer and tobacco smoking.

METHODS

Age-adjusted rates (using the 1970 U.S. standard population) were based on cancer incidence data from NCI and underlying cause of death data compiled by NCHS. The prevalence of tobacco use was derived from CDC surveys. Reported P values are two-sided.

RESULTS

From 1990 through 1996, cancer incidence (-0.9% per year; P = .16) and cancer death (-0.6% per year; P = .001) rates for all sites combined decreased. Among the 10 leading cancer incidence sites, statistically significant decreases in incidence rates were seen in males for leukemia and cancers of the lung, colon/rectum, urinary bladder, and oral cavity and pharynx. Except for lung cancer, incidence rates for these cancers also declined in females. Among the 10 leading cancer mortality sites, statistically significant decreases in cancer death rates were seen for cancers of the male lung, female breast, the prostate, male pancreas, and male brain and, for both sexes, cancers of the colon/rectum and stomach. Age-specific analyses of lung cancer revealed that rates in males first declined at younger ages and then for each older age group successively over time; rates in females appeared to be in the early stages of following the same pattern, with rates decreasing for women aged 40-59 years.

CONCLUSIONS

The declines in cancer incidence and death rates, particularly for lung cancer, are encouraging. However, unless recent upward trends in smoking among adolescents can be reversed, the lung cancer rates that are currently declining in the United States may rise again.

Trends in reported incidence of primary malignant brain tumors in children in the United States

BACKGROUND

The reported incidence of primary malignant brain tumors among children in the United States increased by 35% during the period from 1973 through 1994. The purpose of our study was twofold: 1) to determine whether the reported incidence rates for this period are better represented by a linear increase over the entire period ("linear model") or, alternatively, by a step function, with a lower rate in the years preceding 1984-1985 and a constant higher rate afterward ("jump model"); and 2) to identify the specific brain regions and histologic subtypes that have increased in incidence.

METHODS

Incidence data from the Surveillance, Epidemiology, and End Results Program of the National Cancer Institute for the period from 1973 through 1994 for primary malignant brain tumors in children were used to model the number of cases in a year as a random variable from a Poisson distribution by use of either a linear model or a jump model.

RESULTS/CONCLUSIONS

The increase in reported incidence of childhood primary malignant brain tumors is best explained by the jump model, with a step increase in incidence occurring in the mid-1980s. The brain stem and the cerebrum are the primary sites for which an increase in tumor incidence has been reported. The increase in reported incidence of low-grade gliomas in the cerebrum and the brain stem (unaccompanied by an increase in mortality for these sites) supports the substantial contribution of low-grade gliomas to the overall increase in reported incidence for childhood brain tumors.

IMPLICATIONS

The significantly better fit of the data to a jump model supports the hypothesis that the observed increase in incidence somehow resulted from changes in detection and/or reporting of childhood primary malignant brain tumors during the mid-1980s.

Conditional survival estimates in 34,963 patients with invasive carcinoma of the colon

PURPOSE

We report colon cancer survival rates that are conditioned on patients having already survived one or more years after diagnosis. These rates have more meaning clinically, because they consider those patients who have already survived a given period of time after treatment.

METHODS

The life table method was used to compute conditional survival rates, using population-based data obtained from the Surveillance, Epidemiology, and End Results Program of the National Cancer Institute. Patients were diagnosed between 1983 and 1987 and followed up through 1994. Relative and observed survival rates are considered.

RESULTS

Survival rates up to ten years after diagnosis are reported by stage of disease, gender, and race for colon cancer patients who survived from one to five years after diagnosis. Survival rates are also reported by lymph node involvement.

CONCLUSIONS

Five-year and ten-year survival in colon cancer patients having already survived between one and five years after diagnosis continues to be influenced significantly by stage and race.

Comorbidity and age as predictors of risk for early mortality of male and female colon carcinoma patients: a population-based study

BACKGROUND

Colon carcinoma primarily affects persons 65 years and older. Seventy-five percent of the incident tumors affect persons in this age group. Because of their advanced age, older patients already may be coping with other concomitant major physical illnesses. This article documents preexisting diseases in older colon carcinoma patients at diagnosis and evaluates the effects of their comorbidity burden on early mortality.

METHODS

Prevalence of comorbid conditions was assessed by a retrospective medical records review of an age-stratified random sample of male and female patients aged 55-64 years, 65-74 years, and 75+ years (males, n=799; females, n=811). Data were collected on comorbidity by the National Institute on Aging (NIA) and National Cancer Institute (NCI) and merged with NCI Surveillance, Epidemiology, and End Results (SEER) tumor registry data.

RESULTS

Hypertension, high impact heart conditions, gastrointestinal problems, arthritis, and chronic obstructive pulmonary disease emerged as the most prominent comorbid conditions in the NIA/NCI SEER Study sample. The prevalence of comorbidity in the number and type of conditions was similar for both men and women (e.g., 40% of each gender had > or = 5 comorbidities). Within 2 years of diagnosis, 28% (n=454) of the patients had died. The number of comorbid conditions was significant in predicting early mortality in a model including age, gender, and disease stage (P=0.0007). Certain comorbidities, classified as "current problem," added significantly to a basic model (e.g., heart problems, alcohol abuse, liver disease, and deep vein thrombosis).

CONCLUSIONS

Although disease stage at time of diagnosis of colon carcinoma is a crucial determinant of patient outcome, comorbidity increases the complexity of cancer management and affects survival duration. Cancer control and treatment research questions should address comorbidity issues pertinent to the age group primarily afflicted with colon carcinoma (i.e., the elderly).

Comorbidity and age as predictors of risk for early mortality of male and female colon carcinoma patients: a population-based study

BACKGROUND

Colon carcinoma primarily affects persons 65 years and older. Seventy-five percent of the incident tumors affect persons in this age group. Because of their advanced age, older patients already may be coping with other concomitant major physical illnesses. This article documents preexisting diseases in older colon carcinoma patients at diagnosis and evaluates the effects of their comorbidity burden on early mortality.

METHODS

Prevalence of comorbid conditions was assessed by a retrospective medical records review of an age-stratified random sample of male and female patients aged 55-64 years, 65-74 years, and 75+ years (males, n=799; females, n=811). Data were collected on comorbidity by the National Institute on Aging (NIA) and National Cancer Institute (NCI) and merged with NCI Surveillance, Epidemiology, and End Results (SEER) tumor registry data.

RESULTS

Hypertension, high impact heart conditions, gastrointestinal problems, arthritis, and chronic obstructive pulmonary disease emerged as the most prominent comorbid conditions in the NIA/NCI SEER Study sample. The prevalence of comorbidity in the number and type of conditions was similar for both men and women (e.g., 40% of each gender had > or = 5 comorbidities). Within 2 years of diagnosis, 28% (n=454) of the patients had died. The number of comorbid conditions was significant in predicting early mortality in a model including age, gender, and disease stage (P=0.0007). Certain comorbidities, classified as "current problem," added significantly to a basic model (e.g., heart problems, alcohol abuse, liver disease, and deep vein thrombosis).

CONCLUSIONS

Although disease stage at time of diagnosis of colon carcinoma is a crucial determinant of patient outcome, comorbidity increases the complexity of cancer management and affects survival duration. Cancer control and treatment research questions should address comorbidity issues pertinent to the age group primarily afflicted with colon carcinoma (i.e., the elderly).

Evidence that childhood acute lymphoblastic leukemia is associated with an infectious agent linked to hygiene conditions

OBJECTIVES

The incidence of acute lymphoblastic leukemia (ALL) in children has shown temporal and geographic variation during the 20th century, with higher rates in developed nations appearing in the first half of the century, but with persisting low rates in developing nations. We sought to assess the relation of childhood ALL with hygiene conditions, an aspect of socioeconomic development affecting rates of exposure to infectious agents.

METHODS

Infection patterns for hepatitis A virus (HAV), an agent with a fecal-oral route of transmission, were used to indicate hygiene conditions in different populations, with emphasis on instructive United States and Japanese data. A catalytic model was fit to these data, estimating the HAV force of infection and age-specific seroprevalence rates over time. These analyses were used to assess the temporal relationship of changes in HAV infection rates to changes in childhood leukemia mortality and incidence rates.

RESULTS

We observed an inverse relationship between HAV infection prevalence and rates of childhood leukemia. Further, decreases in the HAV force of infection in the United States and Japan appear to have preceded increases in childhood leukemia rates. We describe a model based on a putative leukemia-inducing agent with a change in infection rate over time correlated with that of HAV that describes well the temporal trends in childhood leukemia rates for White children in the US and for Japanese children.

CONCLUSION

The data suggest that improved public hygiene conditions, as measured by decreased prevalence of HAV infection, are associated with higher childhood ALL incidence rates. The model that we present supports the plausibility of the hypothesis that decreased childhood exposure to a leukemia-inducing agent associated with hygiene conditions leads to higher rates of ALL in children by increasing the frequency of in utero transmission caused by primary infection during pregnancy (or by increasing the number of individuals infected in early infancy because of lack of protective maternal antibodies).

Increased incidence of cancer in infants in the U.S.: 1980-1990

BACKGROUND

During the decade between 1980-1990, the rate of cancer in children in the U.S. increased. It is unknown whether cancer in infancy, which is biologically and clinically different from cancer in older children, also increased.

METHODS

To evaluate changes in cancer incidence in infants in the U.S. age < 1 year, data from the Surveillance, Epidemiology, and End Results (SEER) program and the U.S. Bureau of the Census were used to construct age specific, population-based cancer incidence rates.

RESULTS

Overall, the annual cancer rate in infants increased from 189 cases per million infants between 1979-1981 to 220 between 1989-1991. At both timepoints, female infants had higher cancer rates than male infants. Although the rates for female infants remained stable at 223 between 1979-1981 versus 236 between 1989-1991, rates for male infants increased from 158 to 205 during the same timepoints. Male infants had increased rates of central nervous system (CNS) tumors (P < 0.05), neuroblastoma, and retinoblastoma; female infants had increased rates of teratomas (P < 0.01) and hepatoblastomas. Between 1979-1981, the three most common types of cancer in infants were neuroblastoma, leukemia, and renal tumors (27%, 15%, and 14%, respectively), and were neuroblastoma, CNS tumors, and leukemia between 1989-1991 (27%, 15%, and 13%, respectively).

CONCLUSIONS

This study shows that the rate of certain types of cancer in infants in the U.S. is increasing. Studies of both genetic and environmental factors are needed to explain these increased rates and the changing distribution of cancer in the first year of life.

Long-term cancer patient survival in the United States

Although survival rates are useful for monitoring progress in the early detection and treatment of cancer and are of particular interest to patients with new diagnoses, there are limited population-based estimates of long-term survival rates. We used data collected by the Surveillance, Epidemiology, and End Results Program for cases diagnosed during 1974-1991 and followed through 1992 to estimate relative survival at 5, 10, and 15 years after diagnosis of cancer of the breast, prostate, colon and rectum, and lung. Relative survival after diagnosis of breast and prostate cancer continued to decline up through 15 years after diagnosis, whereas survival after diagnosis of lung and colon or rectal cancer remained approximately constant after 5 and 10 years, respectively. Age-specific patterns of survival varied by site, stage, and demographics. Among patients with localized breast and prostate cancer, women who were younger than age 45 at breast cancer diagnosis and men who were 75 years and older at prostate cancer diagnosis had the poorest relative survival. Relative survival among lung cancer patients decreased with age at diagnosis, regardless of stage or demographics, and age-specific patterns of relative survival for patients with cancer of the colon and rectum differed according to race. Among white patients diagnosed with cancers of the colon and rectum, relative survival did not vary by age at diagnosis; among black patients older than 45 at diagnosis, relative survival decreased with age. This study provides population-based estimates of long-term survival and confirms black/white, male/female, and stage- and age-specific differences for the major cancers.

Cancer incidence and mortality, 1973-1995: a report card for the U.S

BACKGROUND

The American Cancer Society, the National Cancer Institute (NCI), and the Centers for Disease Control and Prevention including the National Center for Health Statistics (NCHS) agreed to produce together an annual "Report Card" to the nation on progress related to cancer prevention and control in the U.S.

METHODS

This report provides average annual percent changes in incidence and mortality during 1973-1990 and 1990-1995, plus age-adjusted cancer incidence and death rates for whites, blacks, Asians and Pacific Islanders, and Hispanics. Information on newly diagnosed cancer cases is based on data collected by NCI, and information on cancer deaths is based on underlying causes of death as reported to NCHS.

RESULTS

For all sites combined, cancer incidence rates decreased on average 0.7% per year during 1990-1995 (P > 0.05), in contrast to an increasing trend in earlier years. Among the ten leading cancer incidence sites, a similar reversal in trends was apparent for the cancers of the lung, prostate, colon/rectum, urinary bladder, and leukemia; female breast cancer incidence rates increased significantly during 1973-1990 but were level during 1990-1995. Cancer death rates for all sites combined decreased on average 0.5% per year during 1990-1995 (P < 0.05) after significantly increasing 0.4% per year during 1973-1990. Death rates for the four major cancers (lung, female breast, prostate, and colon/rectum) decreased significantly during 1990-1995.

CONCLUSIONS

These apparent successes are encouraging and signal the need to maximize cancer control efforts in the future so that even greater in-roads in reducing the cancer burden in the population are achieved.

Waldenström's macroglobulinemia: incidence patterns in the United States, 1988-1994

BACKGROUND

There are few data describing the epidemiologic aspects of Waldenström's macroglobulinemia (WM), a rare lymphoplasmaproliferative disorder.

METHODS

The authors evaluated the incidence of WM reported in 11 population-based cancer registries in the U.S.

RESULTS

A total of 624 cases were diagnosed between January 1, 1988 (when WM became reportable) and December 31, 1994. Age-adjusted incidence rates for WM (per 1 million person-years at risk) were 3.4 among males and 1.7 among females. The rates increased sharply with age, from 0.1 at age < 45 years to 36.3 at age 75+ years (males) and from 0.1 at age < 45 years to 16.4 at age 75+ years (females). The rates for WM were comparable to those for hairy cell leukemia, but considerably lower than those for multiple myeloma or chronic lymphocytic leukemia. Some geographic variation was evident, with age-adjusted rates among white males ranging from 2.2-7.8 across registries. There was no significant change in rates over the 7-year study period (P > 0.05). The markedly higher rates for WM among whites than blacks stand in contrast to multiple myeloma, which occurs twice as often among blacks.

CONCLUSIONS

This survey provides new data regarding the incidence patterns of WM in the U.S. However, further epidemiologic studies with biomarkers are needed to define the environmental, genetic, immunologic, and viral determinants of this rare but distinctive disorder.

Cancer statistics by race and ethnicity

Key findings on cancer incidence and mortality are presented for five racial and ethnic groups in the United States--African Americans, American Indians, Asians and Pacific Islanders, Hispanics, and whites. Information on the prevalence of cancer risk factors and screening examinations among these racial and ethnic groups is also included.

Recent trends in U.S. breast cancer incidence, survival, and mortality rates

BACKGROUND

Clinical trials have demonstrated that use of mammographic screening and advances in therapy can improve prognosis for women with breast cancer.

PURPOSE

We determined the trends in breast cancer mortality rates, as well as incidence and survival rates by extent of disease at diagnosis, for white women in the United States and considered whether these trends are consistent with widespread use of such beneficial medical interventions.

METHODS

We examined mortality data from the National Center for Health Statistics and incidence and survival data by extent of disease from the Surveillance, Epidemiology, and End Results Program of the National Cancer Institute, all stratified by patient age, using statistical-regression techniques to determine changes in the slope of trends over time.

RESULTS

The age-adjusted breast cancer mortality rate for U.S. white females dropped 6.8% from 1989 through 1993. A significant decrease in the slope of the mortality trend of approximately 2% per year was observed in every decade of age from 40 to 79 years of age. Trends in incidence rates were also similar among these age groups: localized disease rates increased rapidly from 1982 through 1987 and stabilized or increased more slowly thereafter; regional disease rates decreased after 1987; and distant disease rates have remained level over the past 20 years. Three-year relative survival rates increased steadily and significantly for both localized and regional disease from 1980 through 1989 in all ages, with no evidence of an increase in slope in the late 1980s.

IMPLICATIONS

The decrease in the diagnosis of regional disease in the late 1980s in women over the age of 40 years likely reflects the increased use of mammography earlier in the 1980s. The increase in survival rates, particularly for regional disease, likely reflects improvements in systemic adjuvant therapy. Statistical modeling indicates that the recent drop in breast cancer mortality is too rapid to be explained only by the increased use of mammography; likewise, there has been no equivalent dramatic increase in survival rates that would implicate therapy alone. Thus, indications are that both are involved in the recent rapid decline in breast cancer mortality rates in the United States.

Conditional survival of 56,268 patients with breast cancer

BACKGROUND

Survival rates calculated from the date of diagnosis may not be predictive of future outcome for patients who have already survived several years after diagnosis. Conditional survival rates are more informative clinically because they take into account survival after diagnosis.

METHODS

Conditional relative survival rates were calculated by the life-table method using data from the Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute.

RESULTS

Survival rates up to 8 years for patients having survived 1, 2, 3, 4 or 5 years after diagnosis are presented by stage of disease for 56,268 women who were diagnosed as having invasive breast cancer from 1983 to 1987.

CONCLUSIONS

Women with Stage IV breast cancer had a better survival as they moved further in time from their diagnosis. Survival rates did not improve for those with Stage I and II disease regardless of the number of years they survived after diagnosis.

Cancer in older persons. Magnitude of the problem--how do we apply what we know?

The elderly experience the major impact of cancer. The incidence rate for those aged 65 and older is 2085.3 per 100,000 as compared with 193.9 per 100,000 for those younger than 65. Overall, 58% of all cancer incidence is in the older segment of the population. Cancer mortality in the elderly now accounts for 67% of all cancer deaths. Data from the National Cancer Institute Surveillance, Epidemiology, and End Results program for 1985-1989 reveal many salient facts. Older persons have a risk of developing cancer 10 times greater than that for individuals younger than 65. This paper outlines the magnitude of the major cancers that affect the elderly. Incidence and mortality data are presented according to individual tumors (colon, rectum, lung/bronchus, pancreas, stomach, urinary bladder, breast, ovary, and prostate). Demographic data from the U.S. Bureau of the Census focus on the expanding elderly population in the United States and projections for the future. Needs for cancer care and treatment for the elderly, already great, are likely to increase. It is imperative that older persons receive special attention for cancer prevention, early diagnosis, and treatment efforts, especially because there is almost always an overlay of other chronic diseases and age-associated declines concurrent with the diagnosis of cancer in the elderly. This paper highlights issues unique to older persons as individuals at high risk for cancer and suggests research strategies that should be made in anticipation of the even greater cancer burden for the elderly as this subset of the population expands.

Cancer in older persons. Magnitude of the problem--how do we apply what we know?

The elderly experience the major impact of cancer. The incidence rate for those aged 65 and older is 2085.3 per 100,000 as compared with 193.9 per 100,000 for those younger than 65. Overall, 58% of all cancer incidence is in the older segment of the population. Cancer mortality in the elderly now accounts for 67% of all cancer deaths. Data from the National Cancer Institute Surveillance, Epidemiology, and End Results program for 1985-1989 reveal many salient facts. Older persons have a risk of developing cancer 10 times greater than that for individuals younger than 65. This paper outlines the magnitude of the major cancers that affect the elderly. Incidence and mortality data are presented according to individual tumors (colon, rectum, lung/bronchus, pancreas, stomach, urinary bladder, breast, ovary, and prostate). Demographic data from the U.S. Bureau of the Census focus on the expanding elderly population in the United States and projections for the future. Needs for cancer care and treatment for the elderly, already great, are likely to increase. It is imperative that older persons receive special attention for cancer prevention, early diagnosis, and treatment efforts, especially because there is almost always an overlay of other chronic diseases and age-associated declines concurrent with the diagnosis of cancer in the elderly. This paper highlights issues unique to older persons as individuals at high risk for cancer and suggests research strategies that should be made in anticipation of the even greater cancer burden for the elderly as this subset of the population expands.

Cancer in older persons. Magnitude of the problem--how do we apply what we know?

The elderly experience the major impact of cancer. The incidence rate for those aged 65 and older is 2085.3 per 100,000 as compared with 193.9 per 100,000 for those younger than 65. Overall, 58% of all cancer incidence is in the older segment of the population. Cancer mortality in the elderly now accounts for 67% of all cancer deaths. Data from the National Cancer Institute Surveillance, Epidemiology, and End Results program for 1985-1989 reveal many salient facts. Older persons have a risk of developing cancer 10 times greater than that for individuals younger than 65. This paper outlines the magnitude of the major cancers that affect the elderly. Incidence and mortality data are presented according to individual tumors (colon, rectum, lung/bronchus, pancreas, stomach, urinary bladder, breast, ovary, and prostate). Demographic data from the U.S. Bureau of the Census focus on the expanding elderly population in the United States and projections for the future. Needs for cancer care and treatment for the elderly, already great, are likely to increase. It is imperative that older persons receive special attention for cancer prevention, early diagnosis, and treatment efforts, especially because there is almost always an overlay of other chronic diseases and age-associated declines concurrent with the diagnosis of cancer in the elderly. This paper highlights issues unique to older persons as individuals at high risk for cancer and suggests research strategies that should be made in anticipation of the even greater cancer burden for the elderly as this subset of the population expands.

Temporal patterns in colorectal cancer incidence, survival, and mortality from 1950 through 1990

BACKGROUND

Colorectal cancer mortality rates among U.S. white males remained relatively constant from 1950 through 1984 but declined sharply from 1985 through 1990. Those for U.S. white females decreased consistently from 1950 through 1984, with an acceleration of the decline from 1985 through 1990.

PURPOSE

A study was planned to investigate patterns in incidence, survival, and mortality rates over time in order to examine possible reasons for the gender difference in mortality trends and for the decrease in the slope of the mortality trends for both males and females in the late 1980s.

METHODS

Incidence and survival data from the Connecticut Cancer Registry were examined to investigate the gender differences in mortality rates from 1950 through 1984. Incidence and survival data from the Surveillance, Epidemiology, and End Results (SEER) Program were investigated to examine reasons for the abrupt downturn in mortality rates for both white males and white females beginning around 1985.

RESULTS

During the period 1950 through 1984, the colorectal cancer incidence rates in Connecticut increased for males and declined slightly for females. Survival rates were similar for both sexes, increasing on average over 1% per year for both females and males from 1950 through 1984. Examination of SEER data from 1975 through 1990 revealed that for both males and females there were 1) declines in overall incidence and mortality rates beginning in the mid-1980s, 2) steady declines in distant disease incidence rates since 1975, 3) increases in regional disease incidence rates until the early 1980s followed by declines in the late 1980s, and 4) increases in local disease incidence rates until the mid-1980s followed by declines in the late 1980s. Age-period-cohort analyses of mortality rates indicated a statistically significant moderation of colorectal cancer risk with both advancing birth cohorts and recent calendar periods.

CONCLUSIONS

The gender differences in colorectal cancer mortality rate trends observed from 1950 through 1984 are due to differences in incidence rate trends between males and females. Declining colorectal mortality rates in the late 1980s for males and females appear to reflect improved early detection. The peaking and subsequent decline of stage-specific incidence rates at later years for successively lower stage indicate sequential stage shifts as cancers are detected increasingly earlier over time. The increased use of sigmoidoscopy and fecal occult blood tests (triggering colonoscopy) appears to have played an important role in reducing colorectal cancer mortality. Improvements in birth cohort trends in risk for colorectal cancer for each sex suggest that lifestyle changes may have also contributed to the steady reductions in colorectal cancer mortality.

Influence of extent of disease, histology, and demographic factors on lung cancer survival in the SEER population-based data

Rates calculated from the Surveillance, Epidemiology, and End Results (SEER) Program are used to show variations in lung cancer survival by prognostic factors with an emphasis on the extent of disease and demographic variables. The analysis is based on 52,755 histologically confirmed cases of invasive lung cancer diagnosed from 1983 through 1987 and 51,377 cases diagnosed from 1977 through 1982. Females survived better than males. In general, white patients survived better than blacks. However, if both race and sex are considered together, black females survived better than white males and white females had the highest rates and black males the lowest. Age, however, proved to be the strongest predictor of survival of the demographic variables. Young females (< 45 years) with non-small cell lung cancer had an 81% 5-year relative survival rate compared to 44% for those 75 years and over. Survival for small cell lung cancer was lower than that for any other histologic type even when stratified on stage of disease (stages I and II, all stages). Survival for stages III and IV did not vary by histologic type. The histologic grade showed prognostic value only for patients assigned stage I. More detailed extent of disease information was used to show how often specific sites of distant metastases are seen at diagnosis. It also demonstrated the inter-relationship of the different extent of disease variables and their effect on outcome.

On the estimation of survival

The advantages and disadvantages of the different methods for calculating survival according to the TNM (Topography, Lymph Node, and Metastasis) are described. Methods include the observed, relative, and conditional survival rates. For large cohorts, relative survival calculated by the life table method is most useful. Conditional survival, which requires long-term follow-up, is clinically the most informative. In addition, follow-up methods employed by tumor registries are considered.

Ovarian cancer. Survival and treatment differences by age

BACKGROUND

Cancer of the ovary is a disease of older American women with an incidence rate of 9.4 per 100,000 for those under 65 compared to 54.8 per 100,000 for those 65 years of age and over.

METHODS

Over 22,000 women were diagnosed with ovarian cancer between 1973 and 1987 within the Surveillance, Epidemiology and End Results (SEER) Program of the National Cancer Institute. SEER is a population-based program that covers nearly 10% of the U.S. population for cancer incidence and survival.

RESULTS

Ovarian cancer survival rates vary dramatically by stage. Within stage, however, differences are noted in survival by age, with younger women surviving better than older women even after adjustment for the general life expectancy of each age group (relative survival). For Stages III-IV disease, women under 45 years of age have a 5-year relative survival rate of over 45% compared to only 8% for those 85 years of age and over. Between 1973-1977 and 1983-1987, the treatment for Stages III-IV disease has changed. For all age groups, there were sharp increases in the percentage having surgery and chemotherapy/hormonal therapy and decreases in those having surgery and radiation as part of the first course of therapy. Over 40% of women 85 years of age and over did not receive any definitive treatment according to the hospital medical record. In 1983-1987, younger women received more combination therapy (surgery with chemotherapy/hormonal therapy) versus older women who received more single modalities such as surgery only or chemotherapy/hormonal therapy only.

CONCLUSIONS

Older women with ovarian cancer are treated less aggressively than their younger counterparts and have poorer survival rates.

Progress in early breast cancer detection

Evidence indicates progress in the early detection of breast cancer. After 1982 there was a reported increase in the incidence of breast cancer, presumably as a result of increased screening for the disease. The increase was especially noted in early stage breast cancer. The incidence of in situ cases also increased. Since 1973 the San Francisco-Oakland Bay area has reported a statistically significant decrease in mortality for white women. The evidence supports continued efforts at early breast cancer detection.