Selected Cancer Control Publications

DCCPS staff members and grantees contribute many important publications to cancer control science. This sample of selected papers and abstracts demonstrates the breadth of research conducted by division staff and its grantees, including important findings in health disparities, genes and the environment, trends, quality of care, cancer communications, behavioral research, cancer survivorship, and tobacco.

Ahles TA, Saykin A, Furstenberg CT, Cole B, Mott LA, Skalla K, Whedon MB, Bivens S, Mitchell T, Greenberg ER, Silberfarb PM. Neuropsychologic impact of standard-dose systemic chemotherapy in long-term survivors of breast cancer and lymphoma. J Clin Oncol 2002 Jan 15;20(2):485-93.

The purpose of this study was to compare the neuropsychologic functioning of long-term survivors of breast cancer and lymphoma who had been treated with standard-dose systemic chemotherapy or local therapy only. CONCLUSION: Data from this study support the hypothesis that systemic chemotherapy can have a negative impact on cognitive functioning as measured by standardized neuropsychologic tests and self-report of memory changes. However, analysis of the Neuropsychological Performance Index suggests that only a subgroup of survivors may experience long-term cognitive deficits associated with systemic chemotherapy.

Anderson ES, Winett RA, Wojcik JR, Winett SG, Bowden T. A computerized social cognitive intervention for nutrition behavior: direct and mediated effects on fat, fiber, fruits and vegetables, self-efficacy, and outcome expectations among food shoppers. Ann Behav Med 2001 Spring;23(2):88-100.

This study examined the direct and mediated impact of a self-administered, computer-based intervention on nutrition behavior self-efficacy and outcome expectations among supermarket food shoppers. The intervention, housed in kiosks in supermarkets and based on social cognitive theory, used tailored information and self-regulation strategies delivered in 15 brief weekly segments. The study sample (n=277), stratified and randomly assigned to treatment or control, was 96 percent female, and 92 percent White, had a median annual income of about $35,000, and had a mean education of 14.78 +/- 2.11 years. About 12 percent of the sample reported incomes of $20,000 or less, and about 20 percent reported 12 years or fewer of education. Analysis of covariance immediately after intervention and at a 4- to 6-month follow-up found that treatment led to improved levels of fat, fiber, and fruits and vegetables. Treatment also led to higher levels of nutrition-related self-efficacy, physical outcome expectations, and social outcome expectations. Logistic regression analysis determined that the treatment group was more likely than the control group to attain goals for fat, fiber, and fruits and vegetables at post-test and to attain goals for fat at follow-up. Latent variable structural equation analysis revealed that self-efficacy and physical outcome expectations mediated treatment effects on nutrition. In addition, physical outcome expectations mediated the effect of self-efficacy on nutrition outcomes. Implications for future computer-based health promotion interventions are discussed.

Barlow WE, Taplin SH, Yoshida CK, Buist DS, Seger D, Brown M. Cost comparison of mastectomy versus breast-conserving therapy for early-stage breast cancer. J Natl Cancer Inst 2001 Mar 21;93(6):447-55.

BACKGROUND: Choice of treatment for early-stage breast cancer depends on many factors, including the size and stage of the cancer, the woman's age, comorbid conditions, and perhaps the costs of treatment. Authors compared the costs of all medical care for women with early-stage breast cancer cases treated by breast-conserving therapy (BCT) or mastectomy. METHODS: A total of 1,675 women 35 years old or older with incident early-stage breast cancer were identified in a large regional nonprofit health maintenance organization in the period 1990 through 1997. The women were treated with mastectomy only (n=183), mastectomy with adjuvant hormonal therapy or chemotherapy (n=417), BCT with radiation therapy (n=405), or BCT with radiation therapy and adjuvant hormonal therapy or chemotherapy (n=670). The costs of all medical care for the period 1990 through 1998 were computed for each woman, and monthly costs were analyzed by treatment, adjusting for age and cancer stage. All statistical tests were two-sided. RESULTS: At six months after diagnosis, the mean total medical care costs for the four groups differed statistically significantly (P:<.001), with BCT being more expensive than mastectomy. The adjusted mean costs were $12,987, $14,309, $14,963, and $15,779 for mastectomy alone, mastectomy with adjuvant therapy, BCT plus radiation therapy, and BCT plus radiation therapy with adjuvant therapy, respectively. At one year, the difference in costs was still statistically significant (P:<.001), but costs were influenced more by the use of adjuvant therapy than by type of surgery. The 1-year adjusted mean costs were $16,704, $18,856, $17,344, and $19,081, respectively. By five years, BCT was less expensive than mastectomy (P:<.001), with 5-year adjusted mean costs of $41,930, $45,670, $35,787, and $39,926, respectively. Costs also varied by age, with women under 65 years having higher treatment costs than older women. CONCLUSIONS: BCT may have higher short-term costs but lower long-term costs than mastectomy.

Breen N, Wagener D, Brown M, Davis B, Ballard-Barbash R. Progress in cancer screening over a decade: results from the 1987, 1992, and 1998 National Health Interview Surveys. J Natl Cancer Inst 2001;93(22):1704-13.

BACKGROUND: Screening to detect cancer early, an increasingly important cancer control activity, cannot be effective unless it is widely used. METHODS: Use of Pap smears, mammography, fecal occult blood tests (FOBTs), sigmoidoscopy, and digital rectal examination (DRE) was evaluated in the 1987, 1992, and 1998 National Health Interview Surveys. Levels and trends in screening use were examined by sex, age, and racial/ethnic group. The effects of income, educational level, and health care coverage were examined within age groups. Logistic regression analyses of 1998 data were used to develop a parsimonious, policy-relevant model. RESULTS: Use of all screening modalities increased over the period examined; for mammography and DRE, the increase was more rapid in the first half of the decade; for the Pap test and sigmoidoscopy, the increase was more rapid in the second half of the decade. Levels of colorectal cancer screening (both sigmoidoscopy and FOBTs) in 1998 were less than the level that prevailed a decade earlier for mammography. Patterns of change for all screening modalities differed between age, sex, and racial/ethnic groups, but prevalence of use during the study, within recommended time intervals, was consistently lower among groups with lower income and less education. Logistic regression analyses indicated that insurance coverage and, to a greater extent, usual source of care had strong independent associations with screening use when age, sex, racial/ethnic group, and educational level were taken into account. CONCLUSIONS: While cancer screening is generally increasing in the United States, use is relatively low for colorectal cancer screening and among groups that lack health insurance or a usual source of care.

Brown ML, Lipscomb J, Snyder C. The burden of illness of cancer: economic cost and quality of life. Annu Rev Public Health 2001;22:91-113. Review.

Cancer is a major public health issue and represents a significant burden of disease. Authors analyze the main measures of burden of disease as they relate to cancer. Specifically, incidence and mortality, years of life lost from cancer, and cancer prevalence are reviewed. Also discussed are the economic burden of cancer, including cost of illness, phase-specific and long-term costs, and indirect costs. Authors then examine the impact of cancer on health-related quality of life as measured in global terms (disability-adjusted life years and quality-adjusted life years) and using evaluation-oriented applications of health-related quality of life scales. Throughout, the relative strengths and weaknesses of the various approaches to measuring the burden of cancer are noted as well as the methodologic challenges that persist in burden-of-illness research. A discussion of the research agenda to improve understanding of the burden of cancer and of illness more generally is included.

Castelao JE, Yuan JM, Skipper PL, Tannenbaum SR, Gago-Dominguez M, Crowder JS, Ross RK, Yu MC. Gender- and smoking-related bladder cancer risk. J Natl Cancer Inst 2001 Apr 4;93(7):538-45.

BACKGROUND: There is growing evidence that when smoking habits are comparable, women incur a higher risk of lung cancer than men. Because smokers are also at risk for bladder cancer, authors investigated possible sex differences in the susceptibility to bladder cancer among smokers. METHODS: A population-based, case-control study was conducted in Los Angeles, CA, involving 1,514 patients with bladder cancer and 1,514 individually matched population control subjects. Information on tobacco use was collected through in-person interviews. Peripheral blood was collected from study participants to measure 3- and 4-aminobiphenyl (ABP)-hemoglobin adducts, a marker of arylamine exposure. Data were analyzed to determine whether the risk of bladder cancer differs between male and female smokers and whether female smokers exhibit higher levels of ABP-hemoglobin adducts than male smokers with comparable smoking habits. All statistical tests were two-sided. RESULTS: Cigarette smokers had a statistically significant 2.5-fold higher risk (95% confidence interval = 2.1 to 3.0) of bladder cancer than never smokers. Use of filtered versus nonfiltered cigarettes, low-tar versus higher tar cigarettes, or the pattern of inhalation did not modify the risk. The risk of bladder cancer in women who smoked was statistically significantly higher than that in men who smoked comparable numbers of cigarettes (P =.016 for sex-lifetime smoking interaction). Consistent with the sex difference in smoking-related bladder cancer risk, the slopes of the linear regression lines of the 3- and 4-ABP-hemoglobin adducts by cigarettes per day were statistically significantly steeper in women than in men (P values for sex differences <.001 and .006, respectively). CONCLUSION: The risk of bladder cancer may be higher in women than in men who smoked comparable amounts of cigarettes.

Colditz GA, Rosner B. Cumulative risk of breast cancer to age 70 years according to risk factor status: data from the Nurses' Health Study. Am J Epidemiol 2000 Nov 15;152(10):950-64.

Because of the temporal relations between reproductive risk factors and incidence of breast cancer, the authors developed a nonlinear Poisson regression that accounts for time and summarizes risk to age 70 years. Reproductive risk factors, benign breast disease, use of postmenopausal hormones, weight, and alcohol intake were evaluated as risk factors. Among 58,520 women aged 30-55 years in 1980, followed through June 1, 1994, 1,761 incident invasive breast cancer cases were identified. All risks are multivariate adjusted. History of benign breast disease is associated with a 57 percent increase (95% confidence interval (CI): 43%, 73%) in cumulative risk of breast cancer by age 70 years. Use of unopposed postmenopausal estrogen from ages 50-60 years increases risk of breast cancer to age 70 by 23 percent (95% CI: 6%, 42%) compared with a woman who never uses hormones. Ten years of use of estrogen plus progestin increases risk to age 70 years by 67 percent (95% CI: 18%, 136%). Compared with never drinking alcohol, one drink per day from age 18 years increases risk to age 70 by seven percent (95% CI: 0%, 13%). Use of unopposed postmenopausal hormones for 10 years significantly increases the risk of breast cancer, and the addition of progestin further increases the risk.

Cronin KA, Feuer EJ. Cumulative cause-specific mortality for cancer patients in the presence of other causes: a crude analogue of relative survival. Stat Med 2000 Jul 15;19(13):1729-40.

A common population-based cancer progress measure for net survival (survival in the absence of other causes) of cancer patients is relative survival. Relative survival is defined as the ratio of a population of observed survivors in a cohort of cancer patients to the proportion of expected survivors in a comparable set of cancer-free individuals in the general public, thus giving a measure of excess mortality due to cancer. Relative survival was originally designed to address the question of whether or not there is evidence that patients have been cured. It has proven to be a useful survival measure in several areas, including the evaluation of cancer control efforts and the application of cure models. However, it is not representative of the actual survival patterns observed in a cohort of cancer patients. This paper suggests a measure for cumulative crude (in the presence of other causes) cause-specific probability of death for a population diagnosed with cancer. The measure does not use cause of death information, which can be unreliable for population cancer registries. Point estimates and variances are derived for crude cause-specific probability of death using relative survival instead of cause of death information. Examples are given for men diagnosed with localized prostate cancer over the age of 70 and women diagnosed with regional breast cancer using Surveillance, Epidemiology, and End Results (SEER) Program data. The examples emphasize the differences in crude and net mortality measures and suggest areas where a crude measure is more informative. Estimates of this type are especially important for older patients as new screening modalities detect cancers earlier and choice of treatment or even "watchful waiting" become viable options.

Cronin KA, Krebs-Smith SM, Feuer EJ, Troiano RP, Ballard-Barbash R. Evaluating the impact of population changes in diet, physical activity, and weight status on population risk for colon cancer (United States). Cancer Causes Control 2001 May;12(4):305-16.

OBJECTIVE: To estimate the effects of observed population-level changes in risk factors on population risk and incidence of disease. METHODS: Trends in a set of risk factors for colon cancer (vegetable intake, red meat intake, alcohol consumption, physical activity levels, and weight status) were modeled for the U.S. adult population over the years 1975-1995 and combined with relative risk estimates from epidemiologic studies and a probability distribution for the induction period to estimate the percentage change in incidence rates from 1985 to 1995 due to the five risk factors. A sensitivity analysis was performed to account for imprecision related to estimates of trends in behavior and epidemiologic risk. RESULTS: Increased vegetable intake and decreased intakes of red meat and alcohol reduced risk, while reduced physical activity and increased body mass index increased risk for colon cancer. When all five factors were considered together, change in the average population relative risk was small and the risk factors accounted for little of the recently observed decline in incidence. CONCLUSIONS: Although these factors have the potential to greatly affect risk of colon cancer and incidence rates, little of that potential was realized since adverse trends neutralized what progress had been made in the areas of vegetable, red meat, and alcohol consumption.

Cruess DG, Antoni MH, Kumar M, McGregor B, Alferi S, Boyers AE, Carver CS, Kilbourn K. Effects of stress management on testosterone levels in women with early-stage breast cancer. Internat J Beh Med 2001;8(3)194-207.

Authors examined the effects of a 10-week, group-based cognitive-behavioral stress management (CBSM) intervention on serum testosterone levels in women with Stage 1 or 2 breast cancer. At four to eight weeks postsurgery, participants were randomized to CBSM (n=24) or to a wait-list control group (n=10). Free and total testosterone was assessed via radioimmunoassay before and after the study period. The participants also completed a questionnaire assessing the degree to which living with breast cancer had led to social and emotional benefits in their life. Authors observed significant decreases in testosterone levels in the CBSM group and no change in the controls. Decreases in testosterone were related to increases in positive contributions. These findings suggest that short-term psychological interventions can help modulate androgen functioning, and these changes are related to enhanced benefit findings observed among women with breast cancer participating in CBSM.

Deimling GT, Schaefer ML, Kahana B, Bowman K. Racial differences in the health of older adult long-term cancer survivors. J Psychosocial Oncology, In press.

The article examines differences between African American and White, older adult, long-term cancer survivors' reported health problems, illness symptoms, functional difficulties, health worries and concerns, and overall perceptions of health. Relationships between demographic factors (including race and age), factors associated with cancer and its treatment, and health perceptions such as disability burden, health concerns and worries, and self-rated global health, are examined in the proposed conceptual model. Results from the adjusted analyses (controlled for cancer and treatment factors) show that African American cancer survivors experience poorer functional health after cancer, perhaps related to more extensive treatment and thus higher functional disability. African American survivors do not report significantly more symptoms attributed to either cancer or its treatment. They do, however, report consistently higher levels of health conditions such as comorbidities and decreased physical functioning, thereby increasing general health vulnerability. Older African American survivors in this study report less concern about recurrence or second cancers, and may need special attention in terms of follow-up care and surveillance for physical signs/symptoms, comorbidities, and screening for second cancers (primary, secondary, and tertiary prevention). Thus, health providers need to consider these diverse health needs when providing care, whether related to cancer or other comorbid conditions.

Etzioni R, Legler JM, Feuer EJ, Merrill RM, Cronin KA, Hankey BF. Cancer surveillance series: interpreting trends in prostate cancer-part III: Quantifying the link between population prostate-specific antigen testing and recent declines in prostate cancer mortality. J Natl Cancer Inst 1999 Jun 16;91(12):1033-9.

BACKGROUND: The objective of this study was to investigate the circumstances under which dissemination of prostate-specific antigen (PSA) testing, beginning in 1988, could plausibly explain the declines in prostate cancer mortality observed from 1992 through 1994. METHODS: Authors developed a computer simulation model by use of information on population-based PSA testing patterns, cancer detection rates, average lead time (the time by which diagnosis is advanced by screening), and projected decreased risk of death associated with early diagnosis of prostate cancer through PSA testing. The model provides estimates of the number of deaths prevented by PSA testing for the 7-year period from 1988 through 1994 and projects what prostate cancer mortality for these years would have been in the absence of PSA testing. RESULTS: Results were generated by assuming a level of screening efficacy similar to that hypothesized for the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial. Under this assumption, the projected mortality in the absence of PSA testing continued the increasing trend observed before 1991 only when it was assumed that the mean lead time was three years or less. Projected mortality trends in the absence of PSA screening were not consistent with pre-1991 increasing trends for lead times of five years and seven years. CONCLUSIONS: When screening is assumed to be at least as efficacious as hypothesized in the PLCO trial, it is unlikely that the entire decline in prostate cancer mortality can be explained by PSA testing based on current beliefs concerning lead time. Only very short lead times would produce a decline in mortality of the magnitude that has been observed.

Fang CY, Manne SL, Pape SJ. Functional impairment, marital quality, and patient psychological distress as predictors of psychological distress among cancer patients' spouses. Health Psychol 2001 Nov;20(6):452-7.

This study investigated contextual determinants of psychological distress among 197 spouses of cancer patients. It was hypothesized that higher levels of patient functional impairment would lead to greater patient distress. Patient distress, in turn, would lead to lower spouse marital satisfaction and ultimately to higher spouse distress. Spouses completed measures of distress and marital quality at three time points. Cancer patients rated their functional impairment and psychological distress at the same time points. Results indicated that at all time points, greater patient impairment was associated with higher levels of patient distress, which, in turn, was related to lower marital satisfaction. However, marital quality was related to spouse distress at only one time point, but spouse distress was directly associated with patient distress at each time point. Implications for cancer patients and spouses are discussed.

Feuer EJ, Merrill RM, Hankey BF. Cancer surveillance series: interpreting trends in prostate cancer-part II: Cause of death misclassification and the recent rise and fall in prostate cancer mortality. J Natl Cancer Inst 1999 Jun 16;91(12):1025-32.

BACKGROUND: The rise and fall of prostate cancer mortality correspond closely to the rise and fall of newly diagnosed cases. To understand this phenomenon, authors explored the role that screening, treatment, iatrogenic (i.e., treatment-induced) deaths, and attribution bias (incorrect labeling of death from other causes as death from prostate cancer) have played in recent mortality trends. METHODS: Joinpoint regression is utilized to assess the recent rise and fall in mortality and the relationship of total U.S. trends to those areas served by NCI's SEER Program. Incidence-based mortality (IBM) is estimated with the use of prostate cancer data from the SEER Program to partition (from overall prostate cancer mortality trends) the contribution of cases diagnosed since the widespread use of prostate-specific antigen (PSA) testing starting in 1987. IBM is also used to examine the contribution of stage at diagnosis to the recent prostate cancer mortality trends. RESULTS: IBM for cases diagnosed since 1987 rose above the pre-1987 secular (i.e., background) trend, peaked in the early 1990s, and almost returned to the secular trend by 1994. This rise and fall of IBM track with the pool of prevalent cases diagnosed within the prior two years. IBM for cases diagnosed with metastatic disease fell starting in 1991, while IBM for those diagnosed with localized/regional disease was relatively flat. CONCLUSIONS: The rise and fall in prostate cancer mortality observed since the introduction of PSA testing in the general population are consistent with a hypothesis that a fixed percent of the rising and falling pool of recently diagnosed patients who die of other causes may be mislabeled as dying of prostate cancer. The decline in IBM for distant stage disease and flat IBM trends for localized/regional disease provide some evidence of improved prognosis for screen-detected cases, although alternative interpretations are possible.

Hankey BF, Feuer EJ, Clegg LX, Hayes RB, Legler JM, Prorok PC, Ries LA, Merrill RM, Kaplan RS. 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. J Natl Cancer Inst 1999 Jun 16;91(12):1017-24.

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. This study provides 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 NCI's SEER 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.

Hankey BF, Ries LA, Kosary CL, Feuer EJ, Merrill RM, Clegg LX, Edwards BK. Partitioning linear trends in age-adjusted rates. Cancer Causes Control 2000 Jan;11(1):31-5.

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 that specific diseases make to an overall trend in order to better understand the impact of interventions and changes in the prevalence of risk factors. This paper provides 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 U.S. 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 percent 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.

Hankey BF, Ries LAG, Edwards BK. The SEER Program: A national resource. Cancer Epidemiol Biomarkers Prev 1999;12:1117-21.

An integral part of the fight against cancer has been the ability to monitor the occurrence of cancer in the population and assess the impact of the introduction of advances in prevention, screening, and treatment. For more than 25 years, these functions have been performed by the SEER Program, which is based at NCI in the Division of Cancer Control and Population Sciences. The purpose of this review is to briefly describe cancer surveillance at NCI. The SEER Program is the centerpiece of these activities, with various surveillance and research functions arrayed around it to take full advantage of its potential.

Hiatt RA, Rimer BK. A new strategy for cancer control research. Cancer Epidemiol Biomarkers Prev 1999 Nov; 8(11):957-64.

As the 21st century dawns, it is time to examine new strategies for cancer control research. We now use a new definition developed by NCI's Cancer Control Program Review Group with an added emphasis on outcomes that improve the quality of life: "Cancer control research is the conduct of basic and applied research in the behavioral, social, and population sciences that, independently, or in combination with biomedical approaches, reduces cancer risk, incidence, morbidity, and mortality and improves quality of life." Cancer control strategies must be based on a recognition of the critical role of human behavior in the control of cancer and must effectively apply the wide-ranging discoveries in the basic cancer sciences, including basic behavioral research, to improve public health. Interventions must be firmly grounded on scientific evidence, especially the findings that result from epidemiological and surveillance research. Epidemiological research is essential to assess the weight of evidence for particular cancer risk-reducing behavioral recommendations. Surveillance research and its application tells us where we are in our progress against cancer, generates hypotheses for more basic research and interventions, and provides important data for understanding the role of health services and policies on cancer outcomes. Research in epidemiology, cancer-related behaviors, and surveillance should be woven together inextricably to optimize progress in the control of cancer. This report sets forth our views of the expanding scope of cancer control research, with examples of NCI programs and initiatives that are designed to advance cancer control well into the next century. For perspective, we provide a backdrop of some salient historical features of cancer control research and the accomplishments of this field to date.

Howe HL, Wingo PA, Thun MJ, Ries LAG, Rosenberg HM, Feigal EG, Edwards BK. The annual report to the nation on the status of cancer (1973 through 1998), featuring cancers with recent increasing trends. J Natl Cancer Inst 2001;93(11):824-42.

The American Cancer Society, the National Cancer Institute, 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 U.S. This 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 percent of total cancer incidence and mortality in the United States. CONCLUSIONS: Overall cancer incidence and death rates continued to decline in the U.S. Future progress will require sustained improvements in cancer prevention, screening, and treatment.

Kim HJ, Fay MP, Feuer EJ, Midthune DN. Permutation tests for joinpoint regression with applications to cancer rates. Stat Med 2000 Feb 15;19(3):335-51.

The identification of changes in the recent trend is an important issue in the analysis of cancer mortality and incidence data. We apply a joinpoint regression model to describe such continuous changes and use the grid-search method to fit the regression function with unknown joinpoints assuming constant variance and uncorrelated errors. We find the number of significant joinpoints by performing several permutation tests, each of which has a correct significance level asymptotically. Each p-value is found using Monte Carlo methods, and the overall asymptotic significance level is maintained through a Bonferroni correction. These tests are extended to the situation with non-constant variance to handle rates with Poisson variation and possibly autocorrelated errors. The performance of these tests is studied via simulations, and the tests are applied to U.S. prostate cancer incidence and mortality rates.

Kerlikowske K, Carney PA, Geller B, Mandelson MT, Taplin SH, Malvin K, Ernster V, Urban N, Cutter G, Rosenberg R, Ballard-Barbash R. Performance of screening mammography among women with and without a first-degree relative with breast cancer. Ann Intern Med 2000;133:855-63.

BACKGROUND: Although it is recommended that women with a family history of breast cancer begin screening mammography at a younger age than average-risk women, few studies have evaluated the performance of mammography in this group. OBJECTIVE: To compare the performance of screening mammography in women with a first-degree family history of breast cancer and women of similar age without such history. DESIGN: Cross-sectional. SETTING: Mammography registries in California (n= 1), New Hampshire (n=1), New Mexico (n=1), Vermont (n=1), Washington state (n=2), and Colorado (n=1). PARTICIPANTS: 389,533 women 30 to 69 years of age who were referred for screening mammography from April 1985 to November 1997. MEASUREMENTS: Risk factors for breast cancer; results of first screening examination captured for a woman by a registry; and any invasive cancer or ductal carcinoma in situ identified by linkage to a pathology database, the SEER Program, or a state tumor registry. RESULTS: The number of cancer cases per 1,000 examinations increased with age and was higher in women with a family history of breast cancer than in those without (3.2 vs. 1.6 for ages 30 to 39 years, 4.7 vs. 2.7 for ages 40 to 49 years, 6.6 vs. 4.6 for ages 50 to 59 years, and 9.3 vs. 6.9 for ages 60 to 69 years). The sensitivity of mammography increased significantly with age (P = 0.001 [chi-square test for trend]) in women with a family history and in those without (63.2% [95% CI, 41.5% to 84.8%] vs. 69.5% [CI, 57.7% to 81.2%] for ages 30 to 39 years, 70.2% [CI, 61.0% to 79.5%] vs. 77.5% [CI, 73.3% to 81.8%] for ages 40 to 49 years, 81.3% [CI, 73.3% to 89.3%] vs. 80.2% [CI, 76.5% to 83.9%] for ages 50 to 59 years, and 83.8% [CI, 76.8% to 90.9%] vs. 87.7% [CI, 84.8% to 90.7%] for ages 60 to 69 years). Sensitivity was similar for each decade of age regardless of family history. The positive predictive value of mammography was higher in women with a family history than in those without (3.7% vs. 2.9%; P = 0.001). CONCLUSIONS: Cancer detection rates in women who had a first-degree relative with a history of breast cancer were similar to those in women a decade older without such a history. The sensitivity of screening mammography was influenced primarily by age.

Kerner JF, Breen N, Tefft MC, Silsby J. Tobacco use among multi-ethnic Latino populations. Ethn Dis 1998;8(2):167-83.

OBJECTIVES: To examine tobacco use among New York City resident Latin Americans from different countries of origin and with different levels of acculturation reflected by language use. DESIGN: Effective health promotion programs, particularly those aimed at smoking cessation and prevention, require careful investigation into possible cultural and societal factors influencing predictors and barriers to preventive health behavior. National data characterizing cigarette smoking behavior among broadly defined racial/ethnic groups (e.g., Black, Hispanic) have rarely examined the extent or importance of cultural variation and acculturation within and among ethnic groups. This report addresses these issues. METHODS: In this study, authors examine self-reported cigarette smoking behavior from a 1992 telephone survey of a quota sample of Puerto Rican, Dominican, Colombian, and Ecuadorian Hispanics living in New York City. Results from these data are compared with results from a random sample of New York City Hispanics from the Tobacco Use Supplement to the 1992-93 Current Population Survey. RESULTS: Both data sets demonstrated that Puerto Ricans were significantly more likely to be current smokers and ever smokers than the other three Latino groups. Among Hispanic women in the quota sample, those who chose to complete the interview in English were much more likely to report ever smoking than those women who chose to complete the interview in Spanish. CONCLUSIONS: The relationship between smoking behavior and acculturation (as measured by language usage) appears to be complex and sensitive to methodological issues of sampling and interview language.

Kerner JF, Trock BJ, Mandelblatt JS. Diseases of the Breast, Lippincott Williams & Wilkins: Philadelphia, 2000; Chapter 64.

Authors contributed Chapter 64, Breast Cancer in Minority Women, to this comprehensive summary of the current knowledge of breast diseases for practicing clinicians and basic scientists.

Lipshultz SE. Ventricular dysfunction clinical research in infants, children, and adolescents. Prog Pediatr Cardiol 2000 Nov 4;12(1):1-28.

The etiology and course of ventricular dysfunction in children is poorly characterized. Furthermore, many changing developmental properties of the pediatric myocardium and differences in the etiologies of ventricular dysfunction in children compared with adults are illustrated in these articles, invalidating the concept that children can safely be considered small adults for the purpose of understanding heart failure pathophysiology and treatment. However, these articles reveal that strikingly little research in children with ventricular dysfunction exists in terms of well-designed large-scale studies of the epidemiology or multicenter controlled clinical therapeutic trials. A future research agenda is proposed to improve understanding etiologies, course, and treatment of ventricular dysfunction in children that is based on organized and funded cooperative groups, because no one pediatric cardiac center treats enough children with a particular etiology of ventricular dysfunction. In conclusion, significant understanding of basic mechanisms of pediatric ventricular dysfunction and effective therapies for adults with ventricular dysfunction exists. A multicenter pediatric cardiac ventricular dysfunction network would allow improved understanding of diseases and treatments, and would result in evidence-based medicine for pediatric patients with ventricular dysfunction.

Makridakis NM, Ross RK, Pike MC, Crocitto LE, Kolonel LN, Pearce CL, Henderson BE, Reichardt JK. Association of mis-sense substitution in SRD5A2 gene with prostate cancer in African American and Hispanic men in Los Angeles, USA. Lancet 1999 Sep 18;354(9183):975-8.

BACKGROUND: Prostate cancer is a very common disease in more-developed countries, but its cause is largely unknown. It is an androgen-dependent cancer, and androgens have been proposed as having a substantial role in predisposition to the disease. Thus, variations in androgen metabolism genes may affect risk of this disease. METHODS: Authors screened 216 African American and 172 Hispanic men with prostate cancer, and 261 African American and 200 Hispanic healthy men (controls), from a large prospective cohort study (the Hawaii-Los Angeles Multiethnic Cohort Study) for a mis-sense substitution in the human prostatic (or type II) steroid 5alpha-reductase (SRD5A2) gene, the product of which controls metabolic activation of testosterone to dihydrotestosterone. This mis-sense substitution results in an alanine residue at codon 49 being replaced with threonine (A49T). Authors also reconstructed this mutation in the SRD5A2 cDNA, and overexpressed the enzyme in mammalian tissue culture cells. FINDINGS: The A49T aminoacid substitution in the SRD5A2 gene increased the risk of clinically significant disease 7.2-fold in African American men (95% CI=2.17-27.91; p=0.001) and 3.6-fold in Hispanic men (1.09-12.27; p=0.04). The mutant enzyme had a higher in-vitro Vmax than the normal enzyme (9.9 vs 1.9 nmol min(-1) mg(-1)). INTERPRETATION: The A49T variant of the SRD5A2 gene may be a significant contributor to the incidence of prostate cancer in African American and Hispanic men in Los Angeles. Authors estimate that the population attributable risk due to this aminoacid substitution for clinically significant disease is about eight percent in both populations. Increased conversion of testosterone to dihydrotestosterone catalyzed by this variant steroid 5alpha-reductase enzyme may be the cause of the increased risk.

Mandelblatt JS, Yabroff KR, Kerner JF. Equitable access to cancer services: A review of barriers to quality care. Cancer 1999 Dec 1;86(11):2378-90. Review.

BACKGROUND: Barriers to cancer care have been documented in nearly all settings and populations; such barriers represent potentially avoidable morbidity or mortality. A conceptual framework was used to describe patient, provider, and system barriers to cancer services. METHODS: A review of the English- language literature on cancer care from 1980-1998 was conducted; key research was summarized for each domain in the conceptual model. RESULTS: Key patient barriers are related to old age, minority race, and low socioeconomic class; the common pathways by which these sociodemographic factors appear to mediate cancer outcomes include social class and race-related or class-related attitudes. Providers are often ill-prepared to communicate the complexities of cancer care to their diverse patient populations; constraints of the medical care system also can impede the delivery of care. To the authors' knowledge, the impact of the rapid growth in managed care organizations (MCOs) on access to care has yet to be evaluated fully. Although MCOs historically have provided high levels of cancer screening in healthy populations, there are fewer data regarding outcomes for elderly and poor populations and for treatment services. CONCLUSIONS: Additional research is needed to develop and test interventions to overcome barriers to care and evaluate the impact of the growth of managed care on access to cancer care for diverse populations.

Mariotto A, Capocaccia R, Verdecchia A, Micheli A, Feuer EJ, Pickle L, Clegg LX. Projecting SEER cancer survival rates to the U.S.: an ecological approach. Cancer Causes Control. In press.

OBJECTIVES: Cancer survival information is available only in areas covered by cancer registration. The objective of this study is to project cancer survival for the entire U.S. as well as states from survival data from NCI's SEER Program. METHODS: Five-year breast, prostate, and colorectal cancer relative survival rates from SEER are regressed on socioeconomic, demographic, and health variables at the county level. These models are first validated by comparing the observed rates with projected rates for counties not used in the estimation process. RESULTS: Education was the best indicator of longer cancer survival. Other important predictors of the geographical variability of survival varied by cancer site. Better survival was predicted for breast and prostate than for colorectal cancer. CONCLUSIONS: Data from cancer registries can be used in ecological models to provide national and state estimates of patients' survival rates. These estimates are useful in targeting areas in which to promote earlier diagnosis or improved access to care, and may also aid in monitoring the quality of survival data collected by individual cancer registries.

Michael YL, Kawachi I, Berkman LF, Holmes MD, Colditz GA. The persistent impact of breast carcinoma on functional health status: prospective evidence from the Nurses' Health Study. Cancer 2000 Dec 1;89(11):2176-86.

BACKGROUND: Although physical and emotional function after the diagnosis of breast carcinoma has been described in clinic populations, to the authors' knowledge no previous study has measured change from the pre-illness level of functional health status in community-dwelling women. METHODS: The authors conducted a 4-year (1992-96) prospective study of functional recovery after breast carcinoma in a large sample of women, aged 54-73 years. They collected multidimensional measures of self-reported functional health status in 1992, before diagnosis of breast carcinoma, and again in 1996, to examine the risk of decline associated with incident breast carcinoma. RESULTS: After adjustment for age, baseline functional health status, and multiple covariates, women who developed incident breast carcinoma were more likely to have experienced reduced physical function, role function, vitality, social function, and increased bodily pain compared with women who remained free of breast carcinoma. Risk of decline was attenuated with increasing time since diagnosis. Risk of decline in physical function was evident across all stages of breast carcinoma, even after adjustment for women undergoing treatment for persistent or recurrent disease. We found evidence that the risk of decline among breast carcinoma cases compared with healthy women was largest among those who were most socially isolated. CONCLUSIONS: Breast carcinoma results in persistent declines in multiple dimensions of functional health status. These prospective data suggest that previous studies reporting no difference in physical function among breast carcinoma cases compared with disease-free women underestimated the deleterious effect of the disease on function. Socially isolated women are an especially vulnerable group.

Michels KB, Giovannucci E, Joshipura KJ, Rosner BA, Stampfer MJ, Fuchs CS, Colditz GA, Speizer FE, Willett WC. Prospective study of fruit and vegetable consumption and incidence of colon and rectal cancers. J Natl Cancer Inst 2000 Nov 1;92(21):1740-52.

BACKGROUND: Frequent consumption of fruit and vegetables has been associated with a reduced risk of colorectal cancer in many observational studies. METHODS: We prospectively investigated the association between fruit and vegetable consumption and the incidence of colon and rectal cancers in two large cohorts: the Nurses' Health Study (88,764 women) and the Health Professionals' Follow-up Study (47,325 men). Diet was assessed and cumulatively updated in 1980, 1984, 1986, and 1990 among women and in 1986 and 1990 among men. The incidence of cancer of the colon and rectum was ascertained up to June or January of 1996, respectively. Relative risk (RR) estimates were calculated with the use of pooled logistic regression models accounting for various potential confounders. All statistical tests were two-sided. RESULTS: With a follow-up including 1,743,645 person-years and 937 cases of colon cancer, authors found little association of colon cancer incidence with fruit and vegetable consumption. For women and men combined, a difference in fruit and vegetable consumption of one additional serving per day was associated with a covariate-adjusted RR of 1.02 (95% confidence interval [CI] = 0.98-1.05). A difference in vegetable consumption of one additional serving per day was associated with an RR of 1.03 (95% CI =0.97-1.09). Similar results were obtained for women and men considered separately. A difference in fruit consumption of one additional serving per day was associated with a covariate-adjusted RR for colon cancer of 0.96 (95% CI = 0.89-1.03) among women and 1.08 (95% CI = 1.00-1.16) among men. For rectal cancer (total, 244 cases), a difference in fruit and vegetable consumption of one additional serving per day was associated with a RR of 1.02 (95% CI = 0.95-1.09) in men and women combined. None of these associations was modified by vitamin supplement use or smoking habits. CONCLUSIONS: Although fruits and vegetables may confer protection against some chronic diseases, their frequent consumption does not appear to confer protection from colon or rectal cancer.

O'Malley AS, Kerner J, Johnson AE, Mandelblatt J. Acculturation and breast cancer screening among Hispanic women in New York City. Am J Public Health 1999 Feb;89(2):219-27.

OBJECTIVES: This study investigated whether acculturation was associated with the receipt of clinical breast examinations and mammograms among Colombian, Ecuadorian, Dominican, and Puerto Rican women aged 18 to 74 years in New York City in 1992. METHODS: A bilingual, targeted, random-digit-dialed telephone survey was conducted among 908 Hispanic women from a population-based quota sample. Outcome measures included ever and recent use of clinical breast examinations and mammograms. Multivariate logistic regression models were used to assess the effect of acculturation on screening use. RESULTS: When demographic, socioeconomic, and health system characteristics and cancer attitudes and beliefs were controlled for, women who were more acculturated had significantly higher odds of ever and recently receiving a clinical breast examination (P < or = .01) and of ever (P < or = .01) and recently (P < or = .05) receiving a mammogram than did less acculturated women. For all screening measures, there was a linear increase in the adjusted probability of being screened as a function of acculturation. CONCLUSIONS: Neighborhood and health system interventions to increase screening among Hispanic women should target the less acculturated.

O'Malley AS, Mandelblatt J, Gold K, Cagney KA, Kerner J. Continuity of care and the use of breast and cervical cancer screening services in a multiethnic community. Arch Intern Med 1997 Jul 14;157(13):1462-70.

OBJECTIVE: To examine how continuity of care affects the use of breast and cervical cancer screening in a multiethnic population. METHODS: All data came from a structured telephone survey of a population-based quota sample designed to determine the cancer prevention needs of multiethnic Blacks and Hispanics in New York, NY, in 1992. The study included 1,420 women of seven racial/ethnic groups: U.S.-born Blacks, English-speaking Caribbean-born Blacks, Haitian Blacks, and Puerto Rican, Dominican, Colombian, and Ecuadorian Hispanics. The main outcome measures were ever and recently having had a Papanicolaou smear, clinical breast examination (CBE), or mammogram. RESULTS: Among respondents who qualified for the survey on the basis of age and ethnicity, the refusal rate for completing the interview was 2.1 percent. Compared with women without a usual site of care, those with a usual site, but no regular clinician, were 1.56, 2.45 (P < or = .01), and 2.32 (P < or = .05) times as likely ever to have received a Papanicolaou smear, CBE, or mammogram, respectively and 1.84, 1.92 (P < or = .05), and 1.75 times as likely to have received a recent Papanicolaou smear, CBE, or mammogram, respectively. Compared with women without a usual site of care, women with a regular clinician at that usual site of care were 2.63 (P < or = .01), 2.83 (P < or = .01), and 2.30 (P < or = .05) times as likely ever to have received a Papanicolaou smear, CBE, or mammogram, and were 2.00 (P < or = .05), 2.65 (P < or =.01), and 1.40 times as likely to have recently received a Papanicolaou smear, CBE, or mammogram, respectively (adjusted odds ratios). For uninsured women, presence of a usual site of care was associated with increases in recent use of cancer screening for all screening tests. CONCLUSIONS: There is a linear trend in increasing breast and cervical cancer screening rates when one goes from having no usual source of care, to having a usual source, and to having a regular clinician at that usual source. Emphasis on continuity of care, especially on usual source of care, may help to bridge the gap in access to cancer prevention services faced by minority women.

Potosky AL, Legler J, Albertsen PC, Stanford JL, Gilliland FD, Hamilton AS, Eley JW, Stephenson RA, Harlan LC. Health outcomes after prostatectomy or radiotherapy for prostate cancer: results from the Prostate Cancer Outcomes Study. J Natl Cancer Inst 2000 Oct 4;92(19):1582-92.

BACKGROUND: Radical prostatectomy and external beam radiotherapy are the two major therapeutic options for treating clinically localized prostate cancer. Because survival is often favorable regardless of therapy, treatment decisions may depend on other therapy-specific health outcomes. In this study, authors compared the effects of two treatments on urinary, bowel, and sexual functions and on general health-related quality of life outcomes over a 2-year period following initial treatment. METHODS: A diverse cohort of patients aged 55-74 years who were newly diagnosed with clinically localized prostate cancer and received either radical prostatectomy (n=1,156) or external beam radiotherapy (n=435) were included in this study. A propensity score was used to balance the two treatment groups because they differed in some baseline characteristics. This score was used in multivariable cross-sectional and longitudinal regression analyses comparing the treatment groups. All statistical tests were two-sided. RESULTS: Almost two years after treatment, men receiving radical prostatectomy were more likely than men receiving radiotherapy to be incontinent (9.6% versus 3.5%; P:<.001) and to have higher rates of impotence (79.6% versus 61.5%; P:<.001), although large, statistically significant declines in sexual function were observed in both treatment groups. In contrast, men receiving radiotherapy reported greater declines in bowel function than did men receiving radical prostatectomy. All of these differences remained after adjustments for propensity score. The treatment groups were similar in terms of general health-related quality of life. CONCLUSIONS: There are important differences in urinary, bowel, and sexual functions more than two years after different treatments for clinically localized prostate cancer. In contrast to previous reports, these outcome differences reflect treatment delivered to a heterogeneous group of patients in diverse health care settings. These results provide comprehensive and representative information about long-term treatment complications to help guide and inform patients and clinicians about prostate cancer treatment decisions.

Ries LA, Wingo PA, Miller DS, Howe HL, Weir HK, Rosenberg HM, Vernon SW, Cronin K, Edwards BK. The annual report to the nation on the status of cancer, 1973-1997, with a special section on colorectal cancer. Cancer 2000 May 15;88(10):2398-424.

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, the North American Association of Central Cancer Registries (NAACCR), and the Centers for Disease Control and Prevention, including the National Center for Health Statistics (NCHS). METHODS: Age-adjusted rates were based on cancer incidence data from NCI and NAACCR and underlying cause of death as compiled by NCHS. Joinpoint analysis was based on NCI 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 10 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 are underway to increase awareness of screening benefits and treatment for colorectal cancer.

Rimer BK. Cancer control research 2001. Cancer Causes Control 2000 Mar;11(3):257-70. Review.

OBJECTIVES: Major societal changes, including the changing demographics of U.S. society and the genetics and communications revolutions, are providing new opportunities to control cancer both in the United States and around the world. This article examines the implications of these trends and other issues in the context of cancer control research. A seven-item strategy for cancer control research is proposed. RESULTS: Epidemiology, statistics, genetics, and biobehavioral research are central disciplines for cancer control research. The identification of particular at-risk populations is increasingly possible. Cancer control research must focus on increasing fundamental knowledge in order to accelerate improvements in cancer prevention and early detection. Cancer control research also must be used to conduct trials of new cancer detection methods, overcome differential participation in cancer screening, develop evidence-based strategies to improve decision-making, and develop evidence-based cancer communications. A comprehensive cancer surveillance system is the foundation for cancer control research. Cancer control research must aim to reduce cancer risk, incidence, and mortality, and improve quality of life. These are important challenges for the new millennium.

Risch HA, McLaughlin JR, Cole DE, Rosen B, Bradley L, Kwan E, Jack E, Vesprini DJ, Kuperstein G, Abrahamson JL, Fan I, Wong B, Narod SA. Prevalence and penetrance of germline BRCA1 and BRCA2 mutations in a population series of 649 women with ovarian cancer. Am J Hum Genet 2001 Mar;68(3):700-10.

A population-based series of 649 unselected incident cases of ovarian cancer diagnosed in Ontario, Canada, during 1995-96 was screened for germline mutations in BRCA1 and BRCA2. Authors specifically tested for 11 of the most commonly reported mutations in the two genes. Then, cases were assessed with the protein-truncation test (PTT) for exon 11 of BRCA1, with denaturing gradient gel electrophoresis for the remainder of BRCA1, and with PTT for exons 10 and 11 of BRCA2. No mutations were found in all 134 women with tumors of borderline histology. Among the 515 women with invasive cancers, 60 mutations were identified, 39 in BRCA1 and 21 in BRCA2. The total mutation frequency among women with invasive cancers, 11.7 percent (95% confidence interval 9.2%-14.8%), is higher than previous estimates. Hereditary ovarian cancers diagnosed at age <50 years were mostly (83%) due to BRCA1, whereas the majority (60%) of those diagnosed at age >60 years were due to BRCA2. Mutations were found in 19 percent of women reporting first-degree relatives with breast or ovarian cancer and in 6.5 percent of women with no affected first-degree relatives. Risks of ovarian, breast, and stomach cancers and leukemias/lymphomas were increased nine-, five-, six- and threefold, respectively, among first-degree relatives of cases carrying BRCA1 mutations, compared with relatives of noncarriers, and risk of colorectal cancer was increased threefold for relatives of cases carrying BRCA2 mutations. For carriers of BRCA1 mutations, the estimated penetrance by age 80 years was 36 percent for ovarian cancer and 68 percent for breast cancer. In breast cancer risk for first-degree relatives, there was a strong trend according to mutation location along the coding sequence of BRCA1, with little evidence of increased risk for mutations in the 5' fifth, but 8.8-fold increased risk for mutations in the 3' fifth (95% CI 3.6-22.0), corresponding to a carrier penetrance of essentially 100 percent. Ovarian, colorectal, stomach, pancreatic, and prostate cancer occurred among first-degree relatives of carriers of BRCA2 mutations only when mutations were in the ovarian cancer-cluster region (OCCR) of exon 11, whereas an excess of breast cancer was seen when mutations were outside the OCCR. For cancers of all sites combined, the estimated penetrance of BRCA2 mutations was greater for males than for females, 53 percent versus 38 percent. Past studies may have underestimated the contribution of BRCA2 to ovarian cancer, because mutations in this gene cause predominantly late-onset cancer, and previous work has focused more on early-onset disease. If confirmed in future studies, the trend in breast-cancer penetrance, according to mutation location along the BRCA1 coding sequence, may have significant impact on treatment decisions for carriers of BRCA1 mutations. BRCA2 mutations may prove to be a greater cause of cancer in male carriers than previously has been thought.

Schneider TR, Salovey P, Apanovitch AM, Pizarro J, McCarthy D, Zullo J, Rothman AJ. The effects of message framing and ethnic targeting on mammography use among low-income women. Health Psychol 2001 Jul;20(4):256-66.

The authors examined the effects that differently framed and targeted health messages have on persuading low-income women to obtain screening mammograms. The authors recruited 752 women over 40 years of age from community health clinics and public housing developments and assigned the women randomly to view videos that were either gain- or loss-framed and either targeted specifically to their ethnic groups or multicultural. Loss-framed, multicultural messages were most persuasive. The advantage of loss-framed, multicultural messages was especially apparent for Anglo women and Latinas but not for African American women. These effects were stronger after six months than after 12 months.

Schulman KA, Berlin JA, Harless W, Kerner JF, Sistrunk S, Gersh BJ, Dube R, Taleghani CK, Burke JE, Williams S, Eisenberg JM, Escarce JJ. The effect of race and sex on physicians' recommendations for cardiac catheterization. N Eng J Med 1999 Feb 25;340:618-26.

BACKGROUND: Epidemiologic studies have reported differences in the use of cardiovascular procedures according to the race and sex of the patient. Whether the differences stem from differences in the recommendations of physicians remains uncertain. METHODS: Authors developed a computerized survey instrument to assess physicians' recommendations for managing chest pain. Actors portrayed patients with particular characteristics in scripted interviews about their symptoms. A total of 720 physicians at two national meetings of organizations of primary care physicians participated in the survey. Each physician viewed a recorded interview and was given other data about a hypothetical patient. He or she then made recommendations about that patient's care. Multivariate logistic-regression analysis was used to assess the effects of the race and sex of the patients on treatment recommendations, while controlling for the physicians' assessment of the probability of coronary artery disease as well as for the age of the patient, the level of coronary risk, the type of chest pain, and the results of an exercise stress test. RESULTS: The physicians' mean (+/-SD) estimates of the probability of coronary artery disease were lower for women (probability, 64.1+/-19.3 percent, vs. 69.2+/-18.2 percent for men; P<0.001), younger patients (63.8+/-19.5 percent for patients who were 55 years old, vs. 69.5+/-17.9 percent for patients who were 70 years old; P<0.001), and patients with nonanginal pain (58.3+/-19.0 percent, vs. 64.4+/-18.3 percent for patients with possible angina and 77.1+/-14.0 percent for those with definite angina; P=0.001). Logistic-regression analysis indicated that women (odds ratio, 0.60; 95 percent confidence interval, 0.4 to 0.9; P=0.02) and Blacks (odds ratio, 0.60; 95 percent confidence interval, 0.4 to 0.9; P=0.02) were less likely to be referred for cardiac catheterization than men and Whites, respectively. Analysis of race-sex interactions showed that Black women were significantly less likely to be referred for catheterization than White men (odds ratio, 0.4; 95 percent confidence interval, 0.2 to 0.7; P=0.004). CONCLUSIONS: Our findings suggest that the race and sex of a patient independently influence how physicians manage chest pain.

Syrjala KL, Schroeder TC, Abrams JR, Atkins TZ, Brown WS, Sanders JE, Schubert MA, Heiman JR. Sexual function measurement and outcomes in cancer survivors and matched controls. J Sex Res 2000 Aug;37(3):213-225.

Depending on diagnosis, gender, and treatment, as few as 10 percent or as many as 90 percent of cancer survivors have reported sexual problems. Inconsistencies and inadequacies in measurement have confounded efforts to fully understand and treat these difficulties. A Sexual Function Questionnaire (SFQ) was developed and administered to 400 cancer survivors or matched, noncancer controls. Participants were sexually active or inactive, male or female, heterosexual or homosexual. Nine subscales and two summary scores had internal reliabilities above .80, with factor loadings above .50 for all items. Test-retest reliability, as well as content, construct, criterion, discriminant, and confirmatory validity supported the measure's psychometric strength. Cancer survivors indicated poorer function than controls, with postmenopausal women reporting the poorest sexual function. Survivors' sexual function dropped significantly posttreatment compared to pretreatment. The SFQ provided a valid, reliable outcome measure for use in cancer research or with other medical groups and physically healthy subjects.

Whalen CK, Jamner LD, Henker B, Delfino RJ. Smoking and moods in adolescents with depressive and aggressive dispositions: evidence from surveys and electronic diaries. Health Psychol 2001 Mar;20(2):99-111.

Surveys and electronic diaries were used to examine depressive and externalizing dispositions as they relate to smoking and moods in 170 early adolescents. Negative moods were prevalent, with anger and anxiety reported on 26 percent-60 percent and sadness on 16 percent-40 percent of occasions. The risk of smoking, urges to smoke, and alcohol intake were elevated in teens with aggressive and depressive dispositions, as were diary reports of feeling hassled, angry, and sad. Girls high in depression and aggression also reported more anxiety, stress, and fatigue and less happiness and well-being than did their peers. For boys, depression seemed to dampen the elevated smoking risks associated with externalizing behaviors. Discussion focuses on gender differences in personality-smoking linkages, adolescent negative affectivity, the unique contributions of survey and diary methods, and the promise of targeted preventive interventions such as affect regulation training.

Wingo PA, Ries LA, Giovino GA, Miller DS, Rosenberg HM, Shopland DR, Thun MJ, Edwards BK. Annual report to the nation on the status of cancer, 1973-1996, with a special section on lung cancer and tobacco smoking. J Natl Cancer Inst 1999 Apr 21;91(8):675-90.

The American Cancer Society, NCI, and the 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.

Wingo PA, Ries LA, Rosenberg HM, Miller DS, Edwards BK. Cancer incidence and mortality, 1973-1995: a report card for the U.S. Cancer 1998 Mar 15;82(6):1197-207.

The American Cancer Society, NCI, and CDC, 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 percent per year during 1990-1995 (P > 0.05), in contrast to an increasing trend in earlier years. Among the 10 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 percent per year during 1990-1995 (P < 0.05) after significantly increasing 0.4 percent 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 inroads in reducing the cancer burden in the population are achieved.

Zheng N, Monckton DG, Wilson G, Hagemeister F, Chakraborty R, Connor TH, Siciliano MJ, Meistrich ML. Frequency of minisatellite repeat number changes at the MS205 locus in human sperm before and after cancer chemotherapy. Environ Mol Mutagen 2000;36(2):134-45.

To determine whether the measurement of repeat number mutations at a minisatellite locus could detect human germline mutations induced by chemotherapy, authors performed a longitudinal study of the mutation frequencies in sperm from 10 patients treated for Hodgkin's disease. Polymerase chain reaction on small pools of DNA equivalent to 100 sperm and Southern blotting were used to screen at least 7,900 sperm in each sample to quantify the mutation frequency at the minisatellite MS205 locus. Pretreatment and posttreatment semen samples were obtained at least two months after completion of therapy from four patients treated with a regimen (Novantrone, Oncovin, vinblastine, and prednisone [NOVP]) that lacks alkylating agents and from three patients treated with regimens (Cytoxan, vinblastine, procarbazine and prednisone/Adriamycin, bleomycin, dacarbazine, lomustine, and prednisone [CVPP/ABDIC] or mechlorethamine, Oncovin, procarbazine, and prednisone [MOPP]) containing alkylating agents. There were no effects of NOVP or CVPP/ABDIC on the mutation frequencies. In the one patient treated with MOPP, the treatment with the highest dose of gonadotoxic alkylating agents, there was a statistically significant increase in mutation frequency from 0.79 percent pretreatment to 1.14 percent posttreatment, indicating induction of mutations in stem spermatogonia. During-treatment semen samples obtained from two patients treated with ABVD, which does not contain gonadotoxic alkylating agents, one with NOVP also did not show any increases above the baseline mutation frequencies, indicating no increase in the minisatellite mutation frequency in spermatocytes. Thus, measurement of repeat number changes at minisatellite MS205 appears to be able to detect induced germline mutations in human sperm. However, most chemotherapy regimens do not significantly increase this class of mutations.