The impact of screening on cancer incidence and mortality in Missouri, USA, 2004-2013.

OBJECTIVES: Population-based evidence regarding impact of cancer screenings and cancer rates in Missouri is lacking. This study examined whether screenings of breast cancer, cervical cancer, and colorectal cancer impact early-stage cancer incidence and mortality in Missouri. STUDY DESIGN: This is an ecological study based on county-specific estimates of selected cancer screening prevalence and early-stage cancer incidence and cancer mortality. METHODS: County-specific prevalence of clinical breast examination, mammography, Pap test, sigmoidoscopy or colonoscopy, and fecal occult blood test (FOBT) were generated from Missouri County-Level Study (2003, 2007, and 2011). County-specific crude incidence and mortality were calculated (2004-2013). Pearson's correlation and Poisson regression were used to test association between cancer rate and screening prevalence. Covariates included county-level mean age, percentage of whites, percentage with low income, percentage with less than high school education high school, percentage with no insurance, and percentage having difficulties accessing care. RESULTS: In the adjusted model, 'ever had Pap test' was significantly associated with an increase of 8% in early-stage cervical cancer incidence. Having clinical breast examination or Pap test in the past was also associated with decreases in mortality by 3% and 4%, respectively, although the association was not significant for Pap test. In addition, having mammography was statistically significantly associated with early-stage breast cancer incidence, and having FOBT or sigmoidoscopy or colonoscopy was associated with decreased colorectal cancer mortality; however, magnitude for these associations was only around 1%. CONCLUSIONS: This study provides ecological evidence of the effectiveness of screening services in predicting early stage cancer incidence and in reducing mortality across Missouri counties. Further incentive to promote these screenings in Missouri is needed.

Dependence in activities of daily living and cognitive impairment strongly predicted mortality in older urban residents in Brazil: a 2-year follow-up.

OBJECTIVES: To identify a set of predictors of mortality among residents in the community, before any physical, biochemical, or image examination is performed, that could be collected on a routine standardized basis, to help the clinician define a patient follow-up strategy and the health planner make decisions regarding the care of older people. DESIGN: A household follow-up study, with an evaluation at baseline and 2 years later. SETTING: Residential area, with a low rate of in- and outmigration, in Sao Paulo, a large industrialized urban center in southeastern Brazil. PARTICIPANTS: One thousand six hundred sixty-seven older urban residents in the community (65+), from different socioeconomic backgrounds, enrolled after a study area census. INTERVENTION: Structured home interview with Brazilian Older Americans Resources and Services Multidimensional Functional Assessment Questionnaire, previously validated in Portuguese. MEASUREMENTS: A logistic regression model for the risk of dying in the period was developed, having as independent variables, sociodemographic characteristics plus six other dimensions: subjective self-evaluation of health, past medical history, use of health services, dependence in activities of daily living (ADLs), mental health, and cognitive status. RESULTS: There were 146 deaths (9%) in the cohort during the follow-up interval. The variables that appeared as independent predictors of death in the final logistic regression model were: gender (relative risk (RR) = 2.8 (males)), age (RR = 2.0 (80+ vs. 65-69)), hospitalization in the previous 6 months (RR = 2.4 (at least one)), dependence in ADLs (RR = 3.0 (assistance required for 7 vs. 0 ADLs)); and cognitive impairment (RR = 1.9 (Mini-Mental State Examination 18 vs. 30)). CONCLUSION: These findings suggest that in developing countries such as Brazil, an assessment of dependence in daily living and cognitive status should be an essential part of any health evaluation of an older person, not only because these variables represent potentially high independent mortality risks, but also because they can be easily and reliably assessed, using well-validated instruments, and may be susceptible to intervention.

Correlates of overweight and weight-loss practices in Missouri.

OBJECTIVE: To examine potential correlates of overweight and weight-loss practices in Missouri. METHODS: Two probability surveys (n=3,010) were used to investigate the associations of sociodemographic and health-related factors with overweight and attempting, exercising, dieting, and desiring to lose weight. RESULTS: Race, gender, and receiving professional advice were strongly associated with being overweight. Gender, receiving professional advice, and leisure-time physical activity were positively associated with attempting and desiring to lose weight. CONCLUSIONS: Public health programs can utilize this knowledge to reduce the prevalence of overweight by encouraging professional advice and promoting regular exercise.

Trends in chronic obstructive pulmonary disease mortality.

This study examines the mortality trends for chronic obstructive pulmonary disease (COPD) among whites and African Americans in Missouri from 1980-1996. Data from the Missouri Center for Health Information Management and Epidemiology were used to calculate mortality rates. Missouri's COPD deaths rose 40.6% from 1980-1996. Projections through the year 2006 predict continued escalation in rates. Much of the growth in COPD can be attributed to heavy tobacco use in the population.

Measuring the impact of prevention research on public health practice.

CONTEXT: Prevention research involves the translation of established and promising methods of disease prevention and health promotion to communities. Despite its importance, relatively little attention has been paid to systematic approaches to determining the impact of prevention research on public health practice. Evaluation of these effects is challenging, particularly in light of multi-factor causation, long time periods between exposure and disease occurrence, and difficulties in determining costs and benefits. OBJECTIVE: To develop a framework that allows the prospective or retrospective evaluation of the effects and effectiveness of prevention research. RESULTS: The proposed framework allows assessment of prevention research in five areas of public health practice: surveillance and disease investigation, program delivery, policies and regulations, recommendations to the public, and public health education and training. A brief case study of environmental tobacco smoke illustrates the public health impact of prevention research. CONCLUSIONS: Greater translation of prevention research findings is needed to accomplish public health goals--efforts are enhanced by academic-practice partnerships. The relevance and utility of the current framework needs additional testing with a variety of public health issues.

Predictors of compliance with recommended cervical cancer screening schedule: a population-based study.

BACKGROUND: The prevalence of routine cervical cancer screening and compliance with screening schedules are low compared to the Year 2000 objectives. Identifying predictors of routine screening and screening schedule compliance will help achieve these objectives. METHODS: We analyzed data from probability samples of 1,609 Missouri women responding to both the 1994 Behavioral Risk Factor Surveillance System (BRFSS) and the Missouri Enhanced Survey (ES). We generated prevalence odds ratios to identify predictors of non-compliance to cervical cancer screening guidelines. Also, among a sample of women reporting a reason for last Pap test, we estimated the relative odds of a screening v. diagnostic exam. RESULTS: In the combined probability sample, compliance with screening schedule was likely among women younger than 50 years of age and women who had either a recent mammography or a clinical breast exam. Being African-American, not experiencing a cost barrier when seeking medical care, having at least a high-school education and health coverage were each associated with an increased compliance with a screening schedule in the combined probability sample. Among women in the combined probability sample, whites, those who experienced no cost barrier to seeking medical care, the non-obese, and those who had a recent mammography were each more likely to have had a screening as opposed to a diagnostic exam. DISCUSSION: Cancer control and cardiovascular (CVD) prevention programs should consider jointly targeting those at high risk for cervical cancer and CVD because of aging and associated high-risk behavior such as non-compliance with cervical cancer screening, smoking, and obesity. Also, further research is needed to examine whether the increased compliance with cervical cancer screening guidelines among African American women may be in part due to higher occurrence of diagnostic Pap smears.

Trends in Missouri lung cancer rates.

This study presents trend analysis of Missouri lung cancer incidence and mortality, and makes comparisons to U.S. rates. Utilizing 1985-1992 data from the Missouri Cancer Registry, we calculated incidence rates by disease diagnosis year. Missouri Center for Health Information Management and Epidemiology data were used to calculate 1980-1996 mortality rates. Missouri's overall yearly lung cancer incidence rate increased from 60.5 to 62.5 per 100,000 during 1985-1992, while lung cancer mortality increased 25% from 1980-1996. The best method to reduce Missouri's rates of lung cancer is tobacco-use prevention and cessation.

Prevalence changes in modifiable cardiovascular disease risk factors in three Missouri regions, 1990-1996.

OBJECTIVES: To determine the prevalence and prevalence trend of modifiable cardiovascular disease (CVD) risk factors among African Americans and whites/others from 1990-1996. We also examined differential changes between African Americans and whites/others during the same time period. METHODS: This study used data from two special Behavioral Risk Factor Surveillance System (BRFSS) based surveys in 1990 (N = 3,000+) and one in 1996 (N = 2,095) that targeted two metropolitan and one rural region in Missouri with substantial minority populations. Risk factors included physical inactivity, obesity, hypertension, unmonitored cholesterol and smoking. The percent change in prevalence estimates and corresponding confidence intervals between survey years were calculated for each of the above risk factors. RESULTS: When compared with Missouri BRFSS data, overall prevalence of smoking, obesity, hypertension and unmonitored cholesterol was higher in the three-region study population than the state as a whole. African-American males did not experience any statistically significant reductions in CVD risk factor prevalence rates between 1990 and 1996, while the increase in obesity was driven mostly by the African-American female subgroup. The least amount of reduction in CVD risk factors was seen in individuals aged 55 or older, with a high school education or less and/or without health insurance. CONCLUSIONS: Individuals of African-American ethnicity, aged 55 or older, with a high school education or less and/or without health insurance need to be the focus of future public health initiatives designed to reduce the prevalence of CVD risk factors.

Trends in breast cancer screening in Missouri from 1987 to 1995, and predictions for the years 2000 and 2010.

BACKGROUND: Breast cancer is a major cause of morbidity and mortality in the United States (U.S.) and Missouri. In 1992, 3,915 new breast cancer cases were diagnosed and in 1995, 1,006 deaths from breast cancer were reported in Missouri. Although breast cancer incidence has increased in Missouri in the past 20 years, there are indications that early detection has also increased during the same period. Knowledge about which segments of the population have experienced the greatest increase in mammography screening rates helps in planning and implementation of breast cancer control programs at the state level. OBJECTIVES: Examine the prevalence and trends of lifetime mammography and 2-year mammography compliance in Missouri by age, race, and education from 1987 to 1995 and make predictions for the years 2000 and 2010. METHODS: We used data from the Missouri Behavioral Risk Factor Surveillance System (BRFSS), 1987 to 1995, to estimate the prevalence of ever having had a mammogram and compliance with mammography screening guidelines within two years by race, age, and education status among Missouri women over age 18. Using linear models, we regressed breast cancer screening prevalence estimates on time to obtain trends and predictions. RESULTS: Overall, African-American women were more likely to have had a lifetime mammogram than white women. However, we found a steady increase in the prevalence of ever having had a mammogram for all groups of women defined by age and education status, except among African Americans. Increase in the prevalence of ever having had a mammogram was much higher in women age 50 and older and slightly higher among women with a high school education or less. The average prevalence of 2-year mammography screening compliance was about 60% for all groups, a rate which did not significantly change between 1987 and 1995. By the year 2000, white women will have mammography rates equal to or higher than African-American women, and the majority of all women age 50 and older (98.3% to 100%) will have had a lifetime mammogram. CONCLUSION: Missouri target populations are predicted to attain Year 2000 National Health Objectives concerning lifetime mammography. Current efforts should be continued in order to maintain levels of mammography, particularly among African-American women.

Trends in cancer incidence and mortality in Missouri.

BACKGROUND: Cancer is the second leading cause of death in Missouri. Several factors influence public health planning and policy-making decisions, including assessment of the trends in disease and in related risk factors, of overall disease burden on the population, and of the effectiveness of intervention programs. To assess the influence of statewide cancer screening, education, and intervention programs on Missouri's cancer burden, recent trends in cancer incidence and mortality rates among Missourians were analyzed. METHODS: Age-standardized cancer incidence rates from 1985-1992 and cancer mortality rates from 1985-1994 and 1990-1996 were calculated by race, age group, and sex using data collected by the Missouri Cancer Registry and the Missouri Center for Health Statistics. Rates for each year examined were logged and regressed onto year. RESULTS: Between 1985 and 1992, the rate of cancer incidence increased by 16.1% (p < .05). From 1985-1994, cancer mortality rate increased by 3.5% (p < .05). Mortality among males, however, decreased between 1990 and 1996. This decrease was particularly pronounced among African-American males. Missouri males endured greater incidence of and mortality from cancer than Missouri females. Elderly males (both African American and white) exhibited the greatest increase in cancer incidence over the periods examined (+27.3% and +31.8% increase respectively, p < .05). Racial differences were nonexistent for cancer incidence rates, but the cancer mortality rate for African Americans was 45% greater than that for whites. CONCLUSIONS: Although Missouri cancer incidence and mortality rates are higher now compared to 16 years ago, data are presented that indicate a slight decline in mortality rates over the past six years. The recent decline (1990-96) in mortality was present only among men, particularly African-American men. The incidence increase was particularly important for women. Despite the implementation of some programs designed to target minorities and undeserved populations at greater risk, these data indicate that large demographic differences in cancer incidence and mortality still persist. A greater commitment to cancer screening, access to treatment, and cancer prevention programs are necessary to meet Missouri's year 2000 goals for cancer incidence and mortality.

Prostate cancer screening--a physician survey in Missouri.

This study investigated prostate cancer screening practices using prostate specific antigen testing (PSA), digital rectal examination (DRE), and transrectal ultrasonography (TRUS) by primary care physicians in Missouri. In 1993, a mail survey was sent to a stratified random sample of 750 physicians whose primary specialty was general practice, family practice, or internal medicine. Three separate mailings resulted in an overall adjusted response rate of 60 percent. Ninety-five percent of physicians were more inclined to use PSA compared with three years previously, with only 45 percent of physicians more inclined to use DRE. An increase in the use of PSA following a negative DRE was reported by 85 percent and a greater inclination to use TRUS following a positive PSA was reported by 90 percent Eighty-six percent agreed with the American Cancer Society (ACS) guidelines on prostate cancer screening. Using logistic regression adjusted across levels of demographic and practice factors, prevalence odds ratios were derived with results indicating that agreement with ACS guidelines and being in private practice are strong predictors of a physician's inclination to routinely screen asymptomatic patients for prostate cancer. Our findings have provided baseline information on prostate cancer screening in Missouri and suggest that primary care physicians view PSA testing as a useful procedure and appear to be using it in a manner similar to the general pattern seen across the country.

Breast cancer incidence and mortality trends in Missouri.

Among women in Missouri as in the United States (U.S.), breast cancer is the leading site of new cancer cases and the second leading cause of cancer deaths. This study examined patterns of breast cancer incidence and mortality among Missouri women. Age-adjusted Missouri incidence (1985-1992) and mortality (1985-1994) data were compared with Surveillance, Epidemiology, and End Results (SEER) data (1985-1992) by race and diagnosis year. Missouri Cancer Registry (MCR) data indicate that there have been no significant changes in breast cancer incidence and mortality rates through the time periods. Incidence rates for Missouri females (White, African-American and All) are significantly lower than SEER rates for all age groups, with greater differences in all races among women over 65. Incidence rates for African-Americans are significantly lower than for whites. However, Missouri mortality rates for African-Americans fluctuate over the period, but are consistently higher than for whites. In addition, African-Americans over age 65 have higher mortality rates in Missouri than in the U.S.

Predictors of mammography utilization in Missouri, 1993-1994.

Mammography utilization data were studied for 915 women from a combined sample of 1994 Missouri Behavioral Risk Factor Surveillance System and a Special Breast and Cervical Cancer Control Project Evaluation Survey, as well as similar data from 6,784 new participants in Missouri's Breast and Cervical Cancer Control Project during 1993-1994. Among women aged 40 and over, having some college education and having health insurance coverage were associated with a higher likelihood of ever having a mammogram. Education, age, health care, Pap testing, and smoking were identified as important predictors of compliance with recommended schedule of yearly mammography among women aged 50 and over.

Health-related behaviors of women physicians vs other women in the United States.

OBJECTIVE: To examine the health-related behaviors of women physicians compared with those of other women of high and not high socioeconomic status and with national goals. METHODS: We examined the results of a questionnaire-based survey of a stratified random sample, the Women Physicians' Health Study, and a US telephone survey (Behavioral Risk Factor Surveillance System of the Centers for Disease Control and Prevention, Atlanta, Ga). We analyzed 3 samples of women aged 30 to 70 years: (1) respondents from the Women Physicians' Health Study (n = 4501); (2) respondents from the Behavioral Risk Factor Surveillance System (n = 1316) of the highest socioeconomic status; and (3) all other respondents from the Behavioral Risk Factor Surveillance System (n = 35,361). RESULTS: Women physicians were more likely than other women of high socioeconomic status and even more likely than other women not to smoke. The few physicians (3.7%) who smoked reported consuming fewer cigarettes per day, and physicians who had stopped smoking reported quitting at a younger age than women in the general population. Women physicians were less likely to report abstaining from alcohol, but those who drank reported consuming less alcohol per episode than other women and were less likely to report binging on alcohol than women in the general population. Unlike women in the general population and even other women of high socioeconomic status, women physicians' reported behaviors exceeded national goals for the year 2000 in all examined behaviors and screening habits. CONCLUSIONS: Women physicians report having generally good health habits even when compared with other socioeconomically advantaged women and report exceeding all examined national goals for personal screening practices and other personal health behaviors. Women physicians' behaviors may provide useful standards for other women in the United States.

Health care coverage: traditional and preventive measures and associations with chronic disease risk factors.

Physician counseling of patients on health related activities is an essential component of chronic disease prevention, however this requires patients to have ready access to health care providers. Previous studies have explored access to health care in terms of health plans and cost without accounting for the lack of preventive coverage inherent in many insurance policies. This study compares two measures of health care access, one using an assessment of cost and health plan availability, and a new coverage measure including preventive services. Data was collected from 2574 adult respondents to the 1991-92 Missouri Behavioral Risk Factor Surveillance System Surveys. Odds ratios were generated for demographic variables, health related behaviors and preventive screening and the two coverage measures. Using health plan and cost 22% lacked full coverage, however including availability of preventive coverage almost 60% lacked full coverage for preventive care. For both coverage measures significant associations were found with age, exercise, marital status, routine checkup and mammography screening. Using the measure of coverage of preventive services, rural residents and those who had never had cholesterol screening were more likely to lack coverage. Inclusion of preventive care in measures of health care coverage may alter previously reported associations with socio-demographic and health related factors. Policy makers should realize that including preventive services in health care coverage greatly increases the number of individuals lacking adequate coverage, and that those lacking adequate coverage are the least likely to undergo preventive screening.