|
|
|
|
|
|
|
|
The cancer registry as a cancer-control tool
The Annual Report to the Nation on the Status of Cancer, 1976 to 2012, appears in this issue of Cancer.[1]
This is the 18th year of the collaboration between scientists at the
National Cancer Institute, the Centers for Disease Control and
Prevention, the North American Association of Central Cancer Registries,
and the American Cancer Society. It is an enduring public-private
partnership that has paid tremendous dividends. Data from state and
National Cancer Institute Surveillance, Epidemiology, and End Results
program-funded registries are analyzed.
The study of registry data or vital registration is of tremendous value and often is underappreciated.[2]
It can help define the cancer problem, determine where anticancer
resources should be focused, and assess the effectiveness of
cancer-control interventions. From a strong registry, trends in
incidence, mortality, and survival can be documented, and risk factors
for disease can be surmised. When registry data include cancer incidence
and initial treatment, differences can be assessed in cancer treatment
patterns.[3]
Variation of care is a common cause of disparity. Documenting it is
useful for health care providers, payers, and policy makers. Public
disclosure creates pressure to improve the quality of care offered.
The
assessment of registry data is an ecologic study. It can demonstrate
whether a public health intervention is truly effective. Many of our
public health interventions (preventative measures, screening tests, and
treatments) are assessed in clinical studies that are divorced from
reality. Clinical trials can demonstrate that an intervention is
efficacious in the population enrolled, but they do not necessarily
predict effectiveness when used in the general population.[4]
The participants or patients in the general population may not be as
healthy as those in the study, and the health care providers may not be
as skilled.
This report to the nation
documents significant declines in the age-adjusted death rate for the
major causes of cancer death in the United States: cancers of the female
breast, prostate, lung, and colorectal cancer. Although there has been
some major cancer-control success, the data demonstrate that we can do
better. There are some populations that have not shared as much in the
declines. Most disconcerting, the report indicates that there are some
who have not shared equally in the reduction in cancer death rates, and
there are diseases in which mortality is increasing.
Registries
have demonstrated a 40% decline in the age-adjusted breast cancer death
rate over the past 25 years. Assessment demonstrates that the declines
are because of improvements in treatment and early detection. Registries
have also provided clear evidence of treatment differences and
state-by-state variation in the mortality decline. This leads to the
conclusion that we can do better for all by better disseminating current
treatment technologies to the entire population.[5]
Lung
cancer death rates have declined significantly for men over the past 25
years and have started to decline for women in the past decade. This is
largely because the tobacco epidemic is modestly receding. The
state-by-state variation in tobacco use today and the state-by-state
differences in tobacco-related disease outcomes reveal an opportunity to
do better.[6]
Lung
screening has recently become available, but it is somewhat
controversial. The American Cancer Society and the US Preventive
Services Task Force have recommended that individuals at high risk for
lung cancer because of age and smoking history with access to
high-quality screening and treatment should consider screening after
being counseled of the potential benefits and risks.[7, 8]
The landmark study demonstrating a 20% relative risk reduction in
screening also demonstrates significant harms when the screening is done
even in the best of centers.[9] This includes very high false-positive rates and even some deaths from the workup of true-positive and false-positive screens.
Colorectal
cancer rates have declined by 43% over the past 25 years. Studies of
attributable fractions indicate that screening is responsible for 53% of
the decline, changes in risk factors account for 35%, and 12% of the
decline is because of improvements in treatment.[10]
There
is substantial opportunity to save even more individuals from death
because of colorectal cancer. States in the northeast of the United
States (such as Massachusetts and New York) have had declines >40%,
whereas states in the south (such as Mississippi and Alabama) have had
declines <10%.[11]
Nearly 40% of Americans aged >50 years are not up to date on
colorectal cancer screening, and a substantial minority of those
diagnosed receive less than optimal treatment.[12]
There has been debate regarding the value and accuracy of the 53% decline in age-adjusted prostate cancer mortality.[13]
Indeed, the debate demonstrates some of the limitations of registry
data. Registries can demonstrate that the decline in prostate cancer
mortality began too early to be attributed solely to screening.[14] There is speculation that some of the decline is artifact.[15]
The rise in mortality that started in the 1970s and the decline that
began in the early 1990s coincided with World Health
Organization-instituted changes in the coding for causes of death.
Improvements in treatment, the use of prostate-specific antigen for
assessment of prostate cancer progression, and the increasing use of
hormone therapies may also have contributed to the decline in mortality.[16]
Compounding the issue, some of these hormone therapies may reduce the
risk of prostate cancer death by increasing the risk of death from
cardiac disease.[17]
Each year, the scientists involved in this report do a deep dive on 1 specific issue in cancer control.[1]
This year, it is liver cancer. Liver cancer is the second most common
cause of cancer death worldwide. For years, liver cancer was less a
problem in the United States, but its incidence and mortality rates are
now rising.
Major risk factors for liver
cancer include alcohol intake, obesity, diabetes, and infection with
viral hepatitis B (HBV) and hepatitis C (HCV). Worldwide, 60% of all
liver cancers are caused by infection, primarily with HBV and HCV. It is
noteworthy that HBV and HCV cause approximately 30% of liver cancers in
the United States. The most common cause in the United States is fatty
liver disease as a consequence of obesity and diabetes.
All
of the major causes of liver cancer are modifiable. Success in stemming
the US epidemic of obesity can lower rates of liver cancer. Simple
precautions can prevent infection. There is evidence that the HBV
vaccine is at least partially responsible for declines in HBV infection
and liver cancer. Treatment for viral hepatitis infection is often
successful and can prevent liver cancer, but it is very expensive.
The
US Centers for Disease Control and Prevention and the US Preventive
Services Task Force have recommended screening for the cohorts at
highest risk for HCV and HBV. This involves 1-time testing for HCV
infection in all Americans born between 1945 and 1965 and HBV screening
for individuals living in the United States but born in sub-Saharan
Africa, Asia, and countries in which HBV infection prevalence is ≥2%.
The
report also discusses cancer incidence and mortality rates by race. One
limitation of registry data is how populations are categorized. In the
United States, Federal law requires the US government to collect health
statistics using racial categories that are defined by the US Office of
Management and Budget 2 to 3 years before every decennial census.[18] These racial and ethnic definitions have changed literally every 10 years.
The
Office of Management and Budget says these categories are
sociopolitical groupings that are not based in biology. They are
categories of convenience.
Some, such as Asian/Pacific Islander, make little sense geographically, culturally, or biologically.[19] Even the more recent move to split Asian/Pacific Islander into Asian and the separate category “Native Hawaiian and Pacific Islander” creates challenges. Still lost in the averaging of data are the generally high prostate and lung cancer incidence rates among Samoan Americans, the high breast and colorectal cancer rates among Native Hawaiians, and the very high rates of liver cancer among Laotian Americans and stomach cancer among Korean Americans. The subdivision of categories also creates the problem of small numbers and especially limits the assessment of mortality data.
Some, such as Asian/Pacific Islander, make little sense geographically, culturally, or biologically.[19] Even the more recent move to split Asian/Pacific Islander into Asian and the separate category “Native Hawaiian and Pacific Islander” creates challenges. Still lost in the averaging of data are the generally high prostate and lung cancer incidence rates among Samoan Americans, the high breast and colorectal cancer rates among Native Hawaiians, and the very high rates of liver cancer among Laotian Americans and stomach cancer among Korean Americans. The subdivision of categories also creates the problem of small numbers and especially limits the assessment of mortality data.
Misattribution of race is a significant issue.[2]
Beginning with the 2000 Census, individuals were allowed to choose
multiple categories. Although patients often declare their race while
they are alive and receiving health care, the health care provider
usually does it for the dead. The misattribution of Hispanic ethnicity
among Filipino patients with Spanish surnames in mortality data is well
documented. All of this makes the study of cancer in populations, and
especially the study of long-term trends, difficult.
The
Institute of Medicine notes that there is tremendous promise in the
focused epidemiological study of better defined populations. Findings
from such research will likely transcend to other populations. We
commonly describe populations by sex and race but can also use
ethnicity, area of residence, area of geographic origin, and
socioeconomic status. Currently, most registries do not collect data on
area of geographic origin or socioeconomic status. However, area of
geographic origin, compared with race, aligns far better with genetics;
and a correlation (if not a direct influence) has been demonstrated
between socioeconomic status or social deprivation over a period of
years with cancer etiology and genomics.[20]
Today's
cancer registry is a powerful public health and cancer-control tool.
The future of the cancer registry involves acquisition of big data from
the electronic medical record. Harmonization of record systems
eventually will permit the direct transfer of data. The future registry
will allow for the correlation of molecular genomics and outcomes. This
will provide new insights into risk and effectiveness. It will make race
and some other population categorizations less relevant or irrelevant.
The challenge will be to use the technology wisely, as privacy concerns
are already threatening some registries.
0 comments :
Post a Comment
Your comments?
Note: Only a member of this blog may post a comment.