Geographical differences in primary therapy for early-stage breast cancer.

BACKGROUND: Breast-conserving surgery may not be uniformly available to all women. We evaluated geographical differences across Connecticut in the proportions of cases with early stage breast cancer treated by partial mastectomy (PM). We also looked at geographical variation in PM with axillary lymph node dissection (AND) and PM with adjuvant radiotherapy (RAD). METHODS: The Connecticut Tumor Registry identified 9106 cases of early disease for 1991 to 1995. Latitude-longitude coordinates for place of residence at diagnosis and initial form of therapy were available for 8795 records. A spatial scan statistic was used to detect geographical differences in treatment rates across the state. RESULTS: A total of 57.7% of early breast cancer cases were treated by PM. Women living around New Haven were less likely than others to be treated in that manner (relative risk [RR] = .86; P = .0001), whereas those living around Norwalk were more likely (RR = 1.26; P = .0001). PM with AND, relative to PM alone, was reported less often for cases from a large area of southwestern Connecticut (RR = .89; P = .0001), but more often for those in north central Connecticut (RR = 1.13; P = .0001). PM with RAD, relative to PM alone, was less common for cases around Danbury (RR = .40; P = .0001) but more common among cases around Hartford (RR = 1.14; P = .0001). CONCLUSIONS: Geographical analysis is a way for physicians and health officials to identify groups of women who may not yet benefit from preferred surgical procedures.

Diminished socioeconomic and racial disparity in the detection of early-stage breast cancer, Connecticut, 1986-1995.

Annual counts, proportional distributions, and age-adjusted incidence rates of disease by stage at diagnosis are reported for 27,970 in situ and invasive breast cancers from the Connecticut Tumor Registry, 1986-1995. Odds ratios for the likelihood of late-stage disease by year of diagnosis, age category, race/ethnicity, and the socioeconomic level of community of residence are presented. More breast cancer is diagnosed today at earlier, treatable stages than was previously the case. Nonetheless, young women, non-whites, and residents of low-to-moderate income census tracts were all at increased risk of being diagnosed with late-stage disease than were their respective reference groups. From 1986 through 1990, there was little change in the greater likelihood that non-whites and disadvantaged women would be diagnosed with late-stage disease. For 1990-95, however, the disparity in late-stage diagnosis by race/ethnicity and socioeconomic standing was greatly decreased.

Incidental findings in a federally-sponsored cancer screening program.

The volume of non-cancer related clinical services and referrals for medical care of women as a consequence of their enrollment in a federally-sponsored breast and cervical cancer screening program was examined. We randomly sampled 100 medical records from among 389 individuals who received cancer screening services through the Connecticut Breast and Cervical Cancer Early Detection Program. Medical record audits tabulated occasions when women were offered or received diagnostic or therapeutic procedures as a by product of their program participation. Breast screening was provided to 100 women and 49 individuals received cervical cancer screening. In addition, 87 percent of the sample were offered or received one or more non-cancer related health services. Physical exams were provided to 86 women, laboratory tests were ordered for 11 individuals and 55 referrals were made to address a myriad of specific medical needs that were uncovered incidental to breast and cervical cancer screening. Among 26 women who did not heed recommendations for follow-up care, cost, inconvenience and beliefs that medical problems were not immediate concerns were cited. Local screening program sponsors should be cognizant that the health care needs and limited resources of some target populations may be substantial. Mechanisms to assure that needed health care is available to individuals should be built and into all categorical health service programs.

Refutation and conjecture around consensus breast cancer screening guidelines.

Public health policy making sometimes goes beyond dispassionate scientific review of data and program analysis to reflect the attitudes and promote the interests of various health care constituencies, professional organizations, consumer groups, and governmental bodies. This article recounts events that precipitated the issuance of guidance about the advisability of periodic screening mammography for women 40 to 49 years of age. It illustrates how a pragmatic choice was born from equal parts of data, the community's underlying value system, and political exigencies. Examining the policy making process will provide public health practitioners greater capacity to find workable solutions in their advocacy of better health for all.

Subject loss in spatial analysis of breast cancer.

Possible selection bias from assignment of latitude-longitude coordinates to the place of residence of all Connecticut women diagnosed with breast cancer from 1992 to 1995 (N = 11,470) was evaluated. Exact address-matching was accomplished for 8,121 records (70.8%) and an additional 1,722 records (15.0%) were matched using relaxed criteria. We did not address-match 1,627 records (14.1%) due to missing address information or limitations of the Geographic Information Systems street file. The age-adjusted likelihood of address-matching records was significantly greater for women of color, those born within Connecticut, residents of urban locales or census tracts with low median family incomes and those cases diagnosed nearer to 1992. Few differences in address-matching were attributable to tumor characteristics or therapeutic modality.

Ongoing physician guidance to achieve periodic mammography of women at an urban health center.

The use of a low-cost behavior prompt at an urban, hospital-based health center that encourages physicians to record and act upon cancer screening information is described. Brief audit forms were incorporated into medical records of all women 40+ years of age seen between June 1994 and March 1996 (approximately 4,700 office visits). Audit forms alerted physicians about women's breast and cervical cancer screening histories and encouraged them to note any screening done or recommended during an office visit. Patient attributes did not readily distinguish who was and was not screened with mammography at recommended intervals, nor whether physicians did or did not address those needs for examination. On the other hand, explicit, continuous monitoring in medical records of the cancer screening status of women was associated with outcome variables. Availability of information on prior cancer screening activities significantly increased the odds that women were "on-time" for examinations as well as that physicians addressed the needs of women who were "past due" for mammograms at the time of their office visits.

The effects of occupation-based social position on mortality in a large American cohort.

OBJECTIVES: Four occupation-based measures were used to derive estimates of social position's effect on all-cause mortality among men and women in a large national cohort. METHODS: The National Longitudinal Mortality Study provided information on principal occupation and 9-year follow-up for 229,851 persons aged 25 through 64 years. Cox's proportional hazards model was used to estimate the age-adjusted risk of death relative to six ordinal categories of social position. The Slope Index of Inequality described average change in death rates across categories. RESULTS: Risk of death was consistently elevated among persons at lower positions in the social hierarchy. Estimates comparing lowest with highest categories varied within a narrow range (1.47-1.92 for men and 1.23-1.55 for women). However, several discrepancies among analyses were noted. The analysis by US census groups revealed nonlinear associations, whereas those using other scales found incremental increases in risk. Effect modification by sex was observed for analyses by two of the four measures. Race/ ethnicity did not modify the underlying association between variables. CONCLUSIONS: Our analysis complements previous findings and supports, with few qualifications, the interchangeability of occupation-based measures of social position in mortality studies. Explanations for why relative risk estimates were modified by sex are offered.

Immunization registry: problems and prospects for boosting vaccine coverage of children.

Case studies are presented on three organizational models for immunization registries in local communities: agency-based, facility-based, and population-based systems. The strengths and limitations of the respective approaches are highlighted. Each model faces three similar challenges: generating "real-time" information on the status of children who fall behind on their immunizations, assuring confidentiality of registrants and medical information, and maintaining operations amidst adverse social conditions that are at the root of underimmunization of children. With sufficient resources and cooperation among many private and public interests, registries have considerable potential to increase vaccination coverage among our population.

Divergent racial trends in mortality from systemic lupus erythematosus.

OBJECTIVE: To compare trends in mortality from systemic lupus erythematosus (SLE) between black and white females in the United States. METHODS: Analysis of nationwide cause of death data collected by the National Center for Health Statistics, 1968 to 1991. RESULTS: During the latter half of the 1968-91 period, trends in SLE mortality for black and white women under age 45 diverged and racial differences in total mortality from SLE widened. Among white females, total SLE mortality has been stable since the late 1970s at a mean annual rate of 4.6 deaths per million. This stability results from a balance between declining risk among whites under age 45 and increasing in those beyond 55. Among blacks, total mortality has risen more than 30% since the late 1970s to a mean annual rate of 18.7 per million. This increase results from a combination of constant risk in black females under 45 and rising risk in women over 55. CONCLUSION: Trends for whites are consistent with a shift in mortality from younger to older women. This shift can be explained by longer postdiagnosis survival resulting from improved clinical management of SLE. The trends for blacks imply higher prevalence of SLE among black females than previously recognized and/or the existence of some impediment to young black females sharing in the full benefits of effective treatment.

The influence of education and experience on ethical attitudes in neonatal intensive care.

A cross-sectional survey of medical students, pediatrics residents, and neonatologists attempted to identify the combined influence of education and experience on ethical attitudes regarding the management of infants weighing less than 750 g at birth. Of the 120 people surveyed, 94 (78%) returned usable surveys. All groups rated quality of life the most important criterion in treatment decisions. Conversely, cost was rated least important by each group. In addition, cost was rated relatively more important by the clinical medical students than by the preclinical students, residents, or neonatologists. The neonatologist was rated the most important decision maker by the neonatologists and the residents. The parents were rated most important by both groups of students. Severe mental retardation was regarded as an unacceptable quality of life by 82% of the neonatologists, 63% of the residents, 61% of the clinical students, and 48% of the preclinical students. Severe cerebral palsy was considered an unacceptable quality of life by 73% of the neonatologists, 63% of the residents, 50% of the clinical students, and only 32% of the preclinical students. Finally, the anticipated long-term outcome of extremely-low-birth-weight infants was viewed more positively by the neonatologists than by the other groups surveyed.

Counseling adolescents for smoking prevention: a survey of primary care physicians and dentists.

Pediatricians, family practitioners, and dentists were questioned in the spring of 1992 about whether they counseled adolescent patients (10 through 18 years old) not to smoke. Of the 674 questionnaires distributed, 443 (66%) were returned and analyzed. Most practitioners could not estimate cigarette use among their adolescent patients. Prevention counseling occurred infrequently, and least often among younger patients. Physicians were more likely than dentists to counsel adolescents. The data highlight the need for continuing training of primary health care practitioners about the importance of counseling adolescents not to smoke.

Detecting colorectal cancer with a large scale fecal occult blood testing program.

The researchers analyzed outcome data for 439 persons who had positive fecal occult blood tests in a 1984 statewide program for Connecticut residents. Among those with positive test results, colorectal cancer was diagnosed in 33 persons, 7.5 percent of the sample, during 3.5 years of follow-up. More than one-half of all cases found, 15 of 29 persons, or 52 percent, were diagnosed with in-situ or localized tumors, which are most likely to be treated successfully. The predictive value of a positive test varied according to the screened person's age and the number of positive tests obtained from that person. Among those 60 years or older, the positive predictive value of the screening test was 9 percent, compared to 3 percent for persons younger than 60 years. Having more than one positive test was associated with a positive predictive value of 12 percent, compared to 5 percent for one positive test. The findings support the use of fecal occult blood testing for early detection of colorectal cancer.

Stomach cancer patterns in European immigrants to Connecticut, United States.

Age-adjusted annual incidence rates of stomach cancer (ICD-9 code #151) were examined for the period 1973-88 among Connecticut residents who were born in the United States or who emigrated from one of five European nations (Italy, Poland, the United Kingdom, Germany, Portugal). Risk of stomach cancer among each of the five immigrant groups was elevated significantly above that of US-born residents. The magnitude of difference ranged from a 1.62-fold excess among persons born in Italy to a 4.27-fold increase in risk among persons born in Portugal. Cancer risk to foreign-born residents was less than that observed in their native countries, with decreases of 25-64 percent found here. Several differences in patient and disease characteristics were observed according to country of birth. Compared with US-born residents, there was a lesser predominance of males among patients born in Italy, Poland, and the UK. Among all foreign-born groups, the gastric cardia was involved less frequently, and the pyloric region more frequently, than in US-born patients. Adenocarcinomas were significantly less common among Polish-born cases. The findings suggest different etiologies in foreign and US-born patients.

Practices around periodic cancer screening by physicians in primary care specialties.

Questionnaires and information packets were distributed to 121 physicians in primary care specialties in central Connecticut to ascertain how periodic cancer screening is performed and monitored. Results of a baseline survey of 52 respondents (51% of active practitioners) are presented here. Only one quarter of respondents noted some formal mechanism in place within their practice to encourage periodic screening of patients. We estimate that only 20-30% of physicians complete cancer screening activities during routine office visits, although respondents noted this to be the most common type of patient encounter. Relatively few physicians reported reliance on either memory aids (17%) or office staff (20%) to prompt screening recommendations. Three of four respondents noted that the sole mechanism they utilize to initiate cancer screening is physician chart review. Likewise, follow-up of scheduled screening activities relies predominantly on chart review or patient review at the time of a subsequent office visit. Use of "tickler files" or scanning of computerized records are considerably less common practices. These data suggest that physicians in primary care practices often function without specific mechanisms to facilitate performance and improve follow-up of health promoting activities.

Enhancing early breast cancer screening: an expanded role for mammography facilities is needed.

Registered mammography facilities in Connecticut were surveyed in 1988 to determine the capacity and scope of services provided to women. A total of 112 responses were analyzed. Early cancer screening service other than mammography are not routinely provided. Less than 50% of facilities offer instruction on breast self-exams or provide physical breast examinations in conjunction with mammograms. Only one in three facilities have mechanisms in place to notify women of their need for periodic screening. We conclude that efforts to expand the scope of screening services offered by mammography facilities may enhance our capacity to detect early breast cancer in women.

Mammography in Connecticut: current estimates of capacity and usage.

All 124 registered mammography facilities in Connecticut were surveyed in 1988 to determine the availability, quality, and usage of mammography services. A total of 112 responses (90% return) were analyzed. By the measures considered here, capacity and quality of mammography in Connecticut is very good to excellent. Services are available in Connecticut in a wide array of locales, times, and settings. Since 1985, 95 new dedicated machines have been put into service. We estimate that current capacity may exceed 400,000 annual studies. Utilization is below current capacity; roughly 155,000 examinations were completed in 1988. Continued recognition of the procedure's effectiveness, particularly in screening women for evidence of early disease, can help reduce the burden of breast cancer.

Encouraging screening mammograms. Results of the 1988 Connecticut Breast Cancer Detection Awareness Campaign.

Connecticut's first Breast Cancer Detection Awareness Campaign during April 1988 offered low-cost screening mammograms ($50) to women over age 34 who had not been previously examined. Following a brief mass media campaign, some 2,500 inquiries about the program were received over a seven-day period, resulting in 1,243 examinations of the detection of eight breast cancers. Program participants cited an enhanced awareness that a baseline examination was due, and knowledge about the availability of low-cost services as reasons for obtaining a screening mammogram. Their reasons for not having been previously screened included not having been advised by physicians to have such an examination (28%); high cost (37%); and failure to recognize the importance of periodic screening (21%). By contrast, relatively few women expressed concern about the test procedure (12%), or fear of finding cancer (9%) as reasons for not being screened previously. These findings underscore the benefit of cancer control efforts to reduce access and information barriers to regular use of mammography by women.

Misclassification of childhood homicide on death certificates.

Suspect classification of homicide deaths of Connecticut residents under 20 years of age was noted for 29 percent of cases examined. Misclassification was attributed to incomplete or erroneous information recorded on the death certificates, rather than errors in the designation of ICD-9 homicide codes. The results have important implications in the interpretation of vital statistics when homicide is listed as the cause of death and underscore the value of record linkage systems.