Ann C. Klassen

Geographical clustering of prostate cancer grade and stage at diagnosis, before and after adjustment for risk factors

BackgroundSpatial variation in patterns of disease outcomes is often explored with techniques such as cluster detection analysis. In other types of investigations, geographically varying individual or community level characteristics are often used as independent predictors in statistical models which also attempt to explain variation in disease outcomes. However, there is a lack of research which combines geographically referenced exploratory analysis with multilevel models. We used a spatial scan statistic approach, in combination with predicted block group-level disease patterns from multilevel models, to examine geographic variation in prostate cancer grade and stage at diagnosis.ResultsWe examined data from 20928 Maryland men with incident prostate cancer reported to the Maryland Cancer Registry during 1992–1997. Initial cluster detection analyses, prior to adjustment, indicated that there were four statistically significant clusters of high and low rates of each outcome (later stage at diagnosis and higher histologic grade of tumor) for prostate cancer cases in Maryland during 1992–1997. After adjustment for individual case attributes, including age, race, year of diagnosis, patterns of clusters changed for both outcomes. Additional adjustment for Census block group and county-level socioeconomic measures changed the cluster patterns further.ConclusionsThese findings provide evidence that, in locations where adjustment changed patterns of clusters, the adjustment factors may be contributing causes of the original clusters. In addition, clusters identified after adjusting for individual and area-level predictors indicate area of unexplained variation, and merit further small-area investigations.

Comorbidity and survival of elderly head and neck carcinoma patients

Alcohol and tobacco, the primary etiologic agents for head and neck carcinoma (HNCA), cause other chronic diseases and may contribute to the high prevalence of comorbid conditions and generally poor survival of persons with HNCA.

Racial/ethnic differences in self-reported racism and its association with cancer-related health behaviors.

OBJECTIVES We used population-based survey data to estimate the prevalence of self-reported racism across racial/ethnic groups and to evaluate the association between self-reported racism and cancer-related health behaviors. METHODS We used cross-sectional data from the 2003 California Health Interview Survey. Questions measured self-reported racism in general and in health care. The cancer risk behaviors we assessed were smoking, binge drinking, not walking, being overweight or obese, and not being up to date with screenings for breast, cervical, colorectal, and prostate cancers. Analyses included descriptive analyses and logistic regression. RESULTS Prevalences of self-reported racism varied between and within aggregate racial/ethnic groups. In adjusted analyses, general racism was associated with smoking, binge drinking, and being overweight or obese; health care racism was associated with not being up to date with screening for prostate cancer. Associations varied across racial/ethnic groups. CONCLUSIONS Associations between general racism and lifestyle behaviors suggest that racism is a potential stressor that may shape cancer-related health behaviors, and its impact may vary by race/ethnicity.

The Healthy Eating Index and Youth Healthy Eating Index Are Unique, Nonredundant Measures of Diet Quality among Low-Income, African American Adolescents

Chronic disease is related to poor diet quality. The Healthy Eating Index (HEI) was developed to assess diet quality. The Youth HEI (YHEI) is an adaptation of the HEI for use with children and adolescents. The objectives were to compare HEI and YHEI scores among adolescents at risk for chronic disease and to compare associations between the scores and health indicators. This cross-sectional study included 2 low-income, urban African American adolescent samples (Challenge, n = 196; Three Generation, n = 121). HEI and YHEI scores were calculated from a FFQ and compared with BMI, body composition, and micronutrient, energy, and dietary intakes. YHEI scores were lower than HEI scores across both adolescent samples (Challenge, 48.94 +/- 9.31 vs. 62.83 +/- 11.75; Three Generation, 47.08 +/- 9.65 vs. 59.93 +/- 11.27; P < 0.001). Females (64.47 +/- 11.70) had higher HEI scores than males (61.15 +/- 11.61) (P < 0.05), but there was no gender difference in YHEI scores. HEI and YHEI scores were associated with higher micronutrient and total energy intakes (r = 0.19-0.76; P < 0.05). Higher percent body/abdominal fat was associated with lower HEI scores (r = -0.17 to -0.19; P < 0.05) but not with YHEI scores. BMI was not associated with either HEI or YHEI scores. In conclusion, many adolescents were consuming diets that placed them at risk for developing chronic disease. Although both the HEI and YHEI are useful in assessing diet quality, the HEI is inversely associated with body composition, a predictor of chronic disease, and accounts for gender differences in the Dietary Guidelines, whereas the YHEI discounts nutrient-poor, energy-dense foods.

Cervical cancer screening practices among older women: results from the Maryland Cervical Cancer Case-Control Study.

Considerable evidence shows a large proportion of older women have either never had a Pap test or have significant gaps in their history of cervical cancer screening. Differences in health care utilization patterns by age, cohort differences in use of medical subspecialities, and provider reluctance to perform cancer screening within the general medical care encounter have been suggested as reasons for underscreening. Our study conducted in 1985 documents prior health care utilization patterns of 153 cases of Maryland women with invasive cervical cancer compared with a matched control group. Analysis within three age groups showed that cases were significantly less likely to have ever had a Pap test or to receive regular Pap testing, primarily due to differences in medical care utilization patterns. Never having an obstetrician-gynecology visit, a recent (less than 3 years) internist visit, or not having any out-patient visit were significant risk factors. Other risks included older age at first Pap test, reporting not being told to have routine Pap tests, and not using contraceptives. In a multiple logistic regression analysis, recent out-patient visits and lifetime use of an obstetrician-gynecologist remained significant after adjusting for age interactions with recent Pap test history, underscoring the importance of medical care utilization patterns for screening of cancer of the uterine cervix among the elderly.

Practice changes in response to the malpractice litigation climate. Results of a Maryland physician survey.

Data from a 1987 survey of Maryland physicians in three specialties (internal medicine, family or general practice, and obstetrics-gynecology) were used to study the types of changes physicians have made in their practices during the last 2 years as a result of the current malpractice litigation climate. Overall, 51% reported making some type of practice change. The practice changes that physicians reported reflect both risk-reduction (e.g., increased use of tests) and risk-avoidance (e.g., cutting back high-risk patients) strategies, although riskreduction actions were reported more frequently. Raising patient fees was also reported. Specialty predicts whether or not physicians make each type of change; in particular, obstetrician-gynecologists are more likely to report practice changes of all types. Prior litigation experience does not, in general, predict practice changes. The implications of the types of changes reported for access to care and costs of care were considered.

Duration of relative protection of screening for cervical cancer

The reduction in cervical cancer among women with at least one previous negative Pap smear can be assessed in terms of the time elapsed since the last smear was taken. One indicator of the utility of screening is the duration of relative protection, commonly calculated as the inverse of the disease odds ratio. Most investigations of the extent of relative protection provided by Pap testing have relied on data from centrally organized screening programs or case-control studies. For geographic areas without mass screening programs or tumor registries, reliance on subject recall of Pap tests is required. We conducted a case-control investigation of cervical cancer and interviewed 153 Maryland women with invasive disease and two control groups: 153 case-nominated controls and 392 randomly selected controls. The duration of relative protection of screening for disease was 4-6 years for both control groups [relative protection (RP) = 4.30, 95% confidence interval (CI) = 1.5-12.7 for neighborhood controls, RP = 3.63, 95% CI = 1.4-9.6 for random controls]. These findings held after adjusting for education, ever treated for a sexually transmitted disease, smoking, age at menarche and at first sexual intercourse, number of pregnancies, lifetime contraceptive use, and utilization of obstetrician-gynecologist services; the RPs increased upon adjustment. However, there was a decline in the RP with increased duration. Our findings are directly comparable to reports where smears have been verified, suggesting that self-reports of previous tests may be reliable as a method to evaluate the utility of screening.

A comparison of three comorbidity indexes in a head and neck cancer population

We explored differences in prognostic ability for mortality of the established and validated Charlson comorbidity index with two other comorbidity indexes developed for this study. Our study was limited to persons diagnosed with HNCA between 1985 and 1993 in a database formed by a linkage of files from the National Cancer Institutes Surveillance, Epidemiology, and End Results Program with Health Care Finance Administration Medicare files (n=9386). Adjusted relative risks (RR) and 95% confidence intervals (95%CI) for comorbidity index scores of 1 or more compared to 0 were (RR=1.50, 95% CI 1.43-1.68) Charlson index, (RR=1.53 95% CI 1.42-1.66) HNCA index, and (RR=1.49, 95% CI 1.32-1.68) ATC index, respectively. The Charlson and HNCA indexes displayed dose-response patterns (P-value for trend <0.0001). Although the ATC index appears promising, the HNCA and Charlson indexes had similar adjusted RRs, dose-response patterns, P-values, and chi-square scores and appear particularly well-suited to the measurement of comorbidity.

Characteristics of Prepared Food Sources in Low-Income Neighborhoods of Baltimore City

The food environment is associated with obesity risk and diet-related chronic diseases. Despite extensive research conducted on retail food stores, little is known about prepared food sources (PFSs). We conducted an observational assessment of all PFSs (N = 92) in low-income neighborhoods in Baltimore. The most common PFSs were carry-outs, which had the lowest availability of healthy food choices. Only a small proportion of these carry-outs offered healthy sides, whole wheat bread, or entrée salads (21.4%, 7.1%, and 33.9%, respectively). These findings suggest that carry-out-specific interventions are necessary to increase healthy food availability in low-income urban neighborhoods.

Factors influencing waiting time and successful receipt of cadaveric liver transplant in the United States. 1990 to 1992.

OBJECTIVES Despite concern about access to liver transplantation, there has been no nationally based analysis of patients waiting for cadaveric liver transplant. Using data from the United Network for Organ Sharing Organ Procurement and Transplantation Network database waiting and recipient lists, we examined the influence of medical and non-medical factors on the length of time patients waited before transplant and whether they survived the wait. METHODS The authors analyzed 7,422 entries to the waiting list from October 1, 1990 to December 31, 1992. Using Cox Proportional Hazard models, time to transplant was modelled by gender, nationality and ethnicity, age, blood type, medical status (critically ill versus non-critical), transplant number (first versus retransplant), United Network for Organ Sharing region of the country, and three measures of local demand and supply of organs. The risk of dying before being allocated an organ was compared with receiving an organ using multiple logistic regression models. RESULTS In addition to differences by medical status, blood type, geographic region, and organ supply and demand, it was found that women, Hispanic-Americans, Asian-Americans, and children waited longer for transplant, whereas foreign nationals and repeat transplant patients waited fewer days. The risk of dying before transplant was greater for critically ill and repeat transplant patients, as well as for women, older patients, Asian-Americans, and African-Americans. Children were less likely to die, as were patients from certain blood groups and geographic regions. CONCLUSIONS Results confirm known patterns of waiting list experience for liver transplant patients, but also identify factors previously unrecognized as influencing waiting time and outcome. Potential explanatory factors and areas for further inquiry are discussed.