The Extreme Variance of Cancer Mortality Rates

The impact of cancer is difficult to measure. It requires a tremendous amount of effort to account for each individual case and further track the patient outcome. In the United States, we have many institutes which track the impact of cancer. This article focuses on key statistics provided by the National Cancer Institute (NCI) (http://statecancerprofiles.cancer.gov/). Some extreme variances of cancer mortality rates from the data provided in this article are:

• In California, Lake County has 89% more cancer deaths Mono County per capita;
• For lung cancer mortality in California, Lake County has 167% more deaths than San Benito County per capita;
• In the United States, Kentucky has 55% more cancer deaths than Utah per capita;
• For colorectal cancer in the United States, the District of Columbia has 77% more deaths than Utah per capita;
• For breast cancer in the United States, Alaska has 44% more deaths than Hawaii per capita.

The NCI 1of 27 Institutes and Centers that comprise the U.S. National Institutes of Health, which is part of the U.S. Department of Health and Human Services. NCI’s responsibilities include conducting and fostering cancer research; reviewing and approving grant-in-aid applications to support promising research projects on the causes, diagnosis, treatment, and prevention of cancer; collecting, analyzing, and disseminating the results of cancer research conducted in the United States and in other countries; and providing training and instruction in cancer diagnosis and treatment. In fulfilling its responsibilities, NCI has built a national network that includes regional and community cancer centers, physicians who are cancer specialists, cooperative groups of clinical researchers, and volunteer and community outreach groups (1).
Analysis of the data provided by the NCI shows the extreme variance of cancer mortality rates between sates and even between counties within the same sate (4). For instance in California, the lowest all-cancer death rate is observed in Mono County (Chart 1) and this rate is almost two times lower that the one observed in Lake County (Chart 2) (the highest all-cancer death rate in California).



*Numbers indicate annual number of deaths per 100,000 in the population.



*Numbers indicate annual number of deaths per 100,000 in the population.

Analysis of a relative contribution of different cancer types to the overall cancer-related deaths shows that lung cancer-related death primarily contributed to the observed differences. San Benito County (the lowest rate) has the lung/bronchus cancer rate that is almost 2.7 lower than the one observed in Lake County (Charts 3 and 4).



*Numbers indicate annual number of deaths per 100,000 in the population.



*Numbers indicate annual number of deaths per 100,000 in the population.

Other types of cancer also contributed to the extreme difference in cancer-related death rates in California but to the lesser extent. The lowest rate of deaths due to breast cancer in women has approximately 1.4 times difference with the highest rate (Calaveras County 19.6/100,000; and Lassen County 27.3/100,000). The lowest rate of death due to the prostate cancer has 1.9 times difference with the highest rate (Tuolumne County 18.1/100,000; and Sutter County 34.7/100,000).
Using extensive data collected and presented by NCI, we identified 10 states with the lowest and 10 states with the highest cancer mortality rates (Charts 5 and 6). Further analysis showed that lung cancer along with the prostate cancer appeared to be the major contributors to the extreme variance in cancer-related death. The lowest rate of deaths due to lung cancer has approximately 3.2 times difference with the highest rate (Utah 23.4/100,000; and Kentucky 74.8/100,000). The lowest rate of deaths due to prostate cancer has approximately 3.0 times difference with the highest rate (Hawaii 13.4/100,000; and District of Columbia 40.8/100,000).

*Numbers indicate annual number of deaths per 100,000 in the population.





Other types of cancer contributed to the lesser extent to the difference in cancer-related death rates. The lowest rate of death due to the colorectal cancer has 1.7 times difference with the highest rate (Utah 12.6/100,000; and District of Columbia 22.4/100,000). The lowest rate of deaths due to breast cancer in women has approximately 1.4 times difference with the highest rate (Hawaii 18.9/100,000; and Alaska 27.4/100,000).
Although the determinants of many geographic patterns remain to be elucidated, it is obvious that variations in cigarette smoking greatly influence the patterns of lung and certain other tobacco-related cancers. The report found that states with high rates of smoking also have high rates of tobacco-related cancers and overall cancer-related deaths. Comparing the state smoking rates (% of adults who smoke): Utah 9.3%; California 14%; Hawaii 15.4%; and West Virginia 26.5%; Kentucky 25.2%; Mississippi 22.7% (7), and the Charts 5 and 6 it becomes clear that states with the lowest smoking rates have the lowest cancer-related death rates and visa versa.
Obesity, physical inactivity, and poor nutrition are major risk factors for cancer, second only to tobacco use (8). Approximately one-third of the more than 500,000 cancer deaths in the US this year can be attributed to poor diet and physical inactivity, while another third is caused by use of tobacco products.
Early detection of cancer through screening has been shown to reduce mortality from cancers of the colon and rectum, breast, and uterine cervix (8). Screening refers to testing in individuals who are asymptomatic for a particular disease (i.e., they have no symptoms that may indicate the presence of disease). In addition to detecting cancer early, screening for colorectal or cervical cancers can identify and result in the removal of precancerous abnormalities, preventing cancer altogether.
This article is brought to you by GenWay Biotech Inc. GenWay offers a cancer assessment aimed to detect 20 different types of cancer in the early stages under the brand name You Test You™, www.youtestyou.com.










References:

1. National Cancer Institute.

2. The National Vital Statistics System.

3. The Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute (NCI).

4. National Cancer Institute: State Cancer Profiles (http://statecancerprofiles.cancer.gov).

5. Centers for Disease Control and Prevention: Cancer prevention and Control – Geographic Variations.

6. National Cancer Institute: Cancer Mortality Maps and Graphs.

7. Kaiser State Health Facts: 50 States Comparison (http://statehealthfacts.org).

8. American Cancer Society. Cancer Facts & Figures 2009. Atlanta: American Cancer Society, 2009.

The Relationship between Cancer and Smoking

The 1982 United States Surgeon General's report stated that "Cigarette smoking is the major single cause of cancer mortality in the United States." (1) This statement is as true today as it was then. Tobacco smoke contains over 4,000 chemical compounds. More than 60 of these are known or suspected to cause cancer. For example, about 90,000 men die of lung cancer each year in the U.S. About 78,700 lung cancer deaths among men are caused by smoking. This means that the smoking causes about 90% of lung cancer deaths among men (2). Statistics also shows that 80% of all lung cancer deaths in women are caused by smoking (2).
Lung cancer is not the only type of cancer that is linked with smoking. Cigarette smoking accounts for at least 30% of all cancer deaths. It is linked with an increased risk of the following cancers: lung, larynx (voice box), oral cavity (mouth, tongue, and lips), pharynx (throat), esophagus (tube connecting the throat to the stomach), stomach, pancreas, cervix, kidney, bladder, acute myeloid leukemia (3).
The effect of smoking on each type of cancer is different. For example, smoking greatly increases the risk of getting and of dying from cancers of the lungs and larynx (voice box). It has a smaller effect on cancer of the cervix.
Lung cancer is the leading cause of cancer death in both men and women, and is one of the hardest cancers to treat. It claims more than 150,000 lives each year (3). Smoking is responsible for almost 9 out of 10 lung cancer deaths. It increases the risk of getting lung cancer by the factors of 23 and 12 in men and women respectively (2). Lung cancer kills more people than cancers of the breast, prostate, colon and pancreas combined. There are tens of millions of current, former and secondhand smokers in the United States, all of whom are at high risk for lung cancer (3).
Former smoker or ex-smoker means someone who has smoked more than 100 cigarettes over his or her lifetime but does not now smoke every day or some days (2). Even decades after quit¬ting, the risk of lung cancer in former smokers is increased by the factors of 9 and 5 in men and women respectively (2). It has been shown that the risk of lung cancer in ex-smokers never returns to the rate seen in persons who have never smoked.
Even if a person never smoked he or she might have been exposed to secondhand smoke. It is a mixture of 2 forms of smoke that come from burning tobacco: sidestream smoke (smoke that comes from the end of a lighted cigarette, pipe, or cigar) and mainstream smoke (smoke that is exhaled by a smoker) (4).
Secondhand smoke is classified as a "known human carcinogen" (cancer-causing agent) by the U.S. Environmental Protection Agency (EPA), the U.S. National Toxicology Program, and the International Agency for Research on Cancer (IARC), a branch of the World Health Organization (5).
Scientific evidence indicates that there is no safe amount of secondhand smoke. Breathing even a little secondhand smoke is harmful to your health. The American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE), the preeminent U.S. standard-setting body on ventilation issues, has concluded that ventilation technology cannot be relied on to completely control health risks from secondhand smoke exposure (5).
Non-smokers who breathe in secondhand smoke take in nicotine and other toxic chemicals just like smokers do. Secondhand smoke causes lung cancer in adults who don’t smoke. In the United States alone, each year it is responsible for about 3,400 lung cancer deaths in non-smoking adults (5). Breathing in secondhand smoke increases your chances of getting lung cancer by 20 percent to 30 percent. Moreover, concentrations of many cancer-causing and toxic chemicals are potentially higher in secondhand smoke than in the smoke inhaled by smokers.
Although no current screening guidelines for the lung cancer are established, the American Cancer Society recommends that people who are at increased risk for lung cancer, such as smokers, former smokers, or secondhand smokers, be aware of their lung cancer risk. They should talk to their doctors about their chances of getting lung cancer and the lung cancer screening (3).
Currently, when lung cancer is detected, the disease has already spread outside the lung in more than half of all cases. Most people with early lung cancer do not have any symptoms, so only a small number of lung cancers are found at an early stage. When lung cancer is found early, it is often because of tests that were being done for something else. Screening is the use of tests or exams to find a disease like cancer in people who don't have any symptoms. Because lung cancer often spreads beyond the lungs before it causes symptoms, a good screening test to find lung cancer early could save many lives (3). This means part of your health care should focus on related screening and preventive measures to help you stay as healthy as possible.
Several testing options could be available for pro-active people who are at increased risk for lung cancer:

Chest x-ray is the first test your doctor will do to look for any spots on the lungs. It is a plain x-ray of your chest. Studies have shown that this kind of screening does not find many lung cancers early enough to improve a person's chance for a cure (3, 6).
CT scan (computed tomography): A CT (or CAT) scan is a special kind of x-ray. Instead of taking just one picture, the CT scanner takes many pictures as it moves around you. A computer then combines these pictures into a picture of a slice of your body. Spiral CT can pick up tumors well under 1 centimeter in size, while chest x-rays detect tumors about one to two centimeters (0.4 to 0.8 inches) in size (3, 6).
MRI scan (magnetic resonance imaging): Like CT scans, MRI scans give detailed pictures of soft tissues in the body. But MRI scans use radio waves and strong magnets instead of x-rays. MRI scans take longer than x-rays -- often up to an hour. MRI scans are useful in finding lung cancer that has spread to the brain or spinal cord (6).
PET scan (positron emission tomography): PET scans use a form of sugar that contains a radioactive atom. Cancer cells in the body absorb large amounts of the sugar. A special camera can then spot the radioactivity. This test can show whether the cancer has spread to the lymph nodes. PET scans are also useful when the doctor thinks the cancer has spread, but doesn't know where (6).
Tests of tissues and cells, such as lung biopsy or sputum cytology, can be used to follow up on imaging tests to be sure that something seen on an imaging test is really lung cancer. These tests are also used to decide the exact type of lung cancer and how far it may have spread (3, 6).
Screening blood tests are offered from the private sector to meet the needs of pro-active people who are at increased risk for lung cancer. It is up to the individual to be aware of their lung cancer risk by determining whether she/he belongs to one or more risk groups such as smokers, former smokers, or secondhand smokers and talk to his/her doctor to determine if screening tests should be implemented. If the health care provider does not cover screening tests which are preferred by the patient, other options are available from the private sector to address these needs at the patient’s own cost.
This article is brought to you by GenWay Biotech Inc. GenWay offers a cancer assessment aimed to detect 20 different types of cancer in the early stages under the brand name You Test You™.
References:
1. U.S. Department of Health and Human Services. The Health Consequences of Smoking – Cancer: A Report of the Surgeon General. Atlanta, GA: U.S, 1982
2. American Cancer Society (ACS), Smoking and Cancer Mortality Table: http://www.cancer.org/docroot/PED/content/PED_10_2X_Smoking_and_Cancer_Mortality_Table.asp
3. American Cancer Society (ACS), Detailed Guide: Lung Cancer.
4. U.S. Department of Health and Human Services. The Health Consequences of Smoking: A Report of the Surgeon General. Atlanta, GA, 2004.
5. U.S. Department of Health and Human Services. The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. Atlanta, GA, 2007
6. American Cancer Society (ACS), Detailed Guide: Lung Cancer - How Is Lung Cancer Diagnosed?

Understanding The Role of the U.S. Preventive Services Task Force (USPSTF)

In November 2009, the U.S. Preventive Services Task Force (USPSTF) published new guidelines for breast cancer screening by mammograms which sparked controversy on a vital topic to cancer organizations worldwide, the importance of early cancer detection. These new guidelines are a significant shift from those issued in 2002, which at that time, recommended women ages 40 and older to have an annual mammogram. The new recommended ages by the USPSTF to screen women for breast cancer is now 50 and older, leading to many questions on why such a change in policy is necessary.
Immediately after this recommendation from the USPSTF, a statement from Otis W. Brawley, M.D., chief medical official of The American Cancer Society, stated, “The American Cancer Society continues to recommend annual screening using mammography and clinical breast examination for all women beginning at age 40….reasonable experts can look at the same data and reach different conclusions….the Society’s panel found convincing evidence that screening with mammography reduces breast cancer mortality in women ages 40-74…. With its new recommendations, the USPSTF is essentially telling women that mammography at age 40 to 49 saves lives; just not enough of them… The most recent data show us that approximately 17 percent of breast cancer deaths occurred in women who were diagnosed in their 40s.” According to the American Cancer Society’s cancer statistics, this 17% represents approximately 7,000 lives, which will be left at risk once these breast cancer screening policy changes take effect.
Additional support for breast cancer screening comes from researchers at the University of London, which conducted two studies looking into the risks and benefits of breast cancer screening. The first study predicted the number of women who would have died from breast cancer in Britain without screening. The second study evaluated the number of deaths among 80,000 Swedish women with access to screening programs. The results published in the Journal of Medical Screening showed that for every 28 breast cancer diagnoses between 2 and 2.5 lives were saved. The results from the Swedish study indicated that for every 350 women screened for 10 years for breast cancer, one life would be saved. This research, along with hundreds of other publications, indicates an opportunity for saving lives from further development and implementation of cancer screening.
As stated on the Agency for Healthcare Research and Quality’s website (www.ahrq.gov), the USPSTF mission is “to improve the safety, quality, efficiency, and effectiveness of health care for all Americans.” The recommendations of the USPSTF are considered to be the “gold standard” for clinical preventive services, and are followed by almost every major primary care and federal agency associated with health care. USPSTF recommendations are used in undergraduate and post-graduate medical and nursing education as a key reference for teaching preventive care.
So what is the reasoning behind the USPSTF’s breast cancer screening recommendation? False positives can lead to psychological distress, unnecessary imaging tests and biopsies in women without cancer, and inconvenience due to false-positive screening results. Radiation exposure, although a minor concern from mammograms, is also a consideration. The USPSTF recommends that physicians be required to consider additional factors, such as an individual’s personal risk of having cancer, before conducting screening procedures such as mammograms.
It is up to the individual and his/her doctor to determine if screening tests will be implemented. If the health care provider does not cover screening tests which are preferred by the patient, other options are available from the private sector to address these needs at the patient’s own cost.
This article is brought to you by GenWay Biotech Inc. GenWay offers a cancer assessment aimed to detect 20 different types of cancer in the early stages under the brand name You Test You™. To learn more, please visit the website www.youtestyou.com.

References:
1. Agency for Healthcare Research and Quality, Rockville, MD
2. American Cancer Society (ACS) American Cancer Society Responds to Changes to USPSTF Mammography Guidelines. http://www.cancer.org/docroot/MED/content/MED_2_1x_American_Cancer_Society_Responds_to_Changes_to_USPSTF_Mammography_Guidelines.asp
3. American Cancer Society (ACS) Cancer Statistics 2009. http://www.cancer.org/docroot/PRO/content/PRO_1_1_Cancer_Statistics_2009_Presentation.asp
4. Duffy, S., McCann, J., Godward, S., Gabe, R., Warwick, J. “Some issues in screening for breast and other cancers.” Journal of Medical Screening. 2006; 13(Suppl1): S28-S34
5. U.S. Preventive Services Task Force. Screening for breast cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2009;151:716-26, W-236. [PMID: 19920272]