Priti Bandi

Annual Report to the Nation on the Status of Cancer, 1975–2009, Featuring the Burden and Trends in Human Papillomavirus (HPV)–Associated Cancers and HPV Vaccination Coverage Levels

Background The American Cancer Society (ACS), the Centers for Disease Control and Prevention (CDC), the National Cancer Institute (NCI), and the North American Association of Central Cancer Registries (NAACCR) collaborate annually to provide updates on cancer incidence and death rates and trends in these outcomes for the United States. This year’s report includes incidence trends for human papillomavirus (HPV)–associated cancers and HPV vaccination (recommended for adolescents aged 11–12 years). Methods Data on cancer incidence were obtained from the CDC, NCI, and NAACCR, and data on mortality were obtained from the CDC. Long- (1975/1992–2009) and short-term (2000–2009) trends in age-standardized incidence and death rates for all cancers combined and for the leading cancers among men and among women were examined by joinpoint analysis. Prevalence of HPV vaccination coverage during 2008 and 2010 and of Papanicolaou (Pap) testing during 2010 were obtained from national surveys. Results Death rates continued to decline for all cancers combined for men and women of all major racial and ethnic groups and for most major cancer sites; rates for both sexes combined decreased by 1.5% per year from 2000 to 2009. Overall incidence rates decreased in men but stabilized in women. Incidence rates increased for two HPV-associated cancers (oropharynx, anus) and some cancers not associated with HPV (eg, liver, kidney, thyroid). Nationally, 32.0% (95% confidence interval [CI] = 30.3% to 33.6%) of girls aged 13 to 17 years in 2010 had received three doses of the HPV vaccine, and coverage was statistically significantly lower among the uninsured (14.1%, 95% CI = 9.4% to 20.6%) and in some Southern states (eg, 20.0% in Alabama [95% CI = 13.9% to 27.9%] and Mississippi [95% CI = 13.8% to 28.2%]), where cervical cancer rates were highest and recent Pap testing prevalence was the lowest. Conclusions The overall trends in declining cancer death rates continue. However, increases in incidence rates for some HPV-associated cancers and low vaccination coverage among adolescents underscore the need for additional prevention efforts for HPV-associated cancers, including efforts to increase vaccination coverage.

Association of Insurance with Cancer Care Utilization and Outcomes

Advances in the prevention, early detection, and treatment of cancer have resulted in an almost 14% decrease in the death rates from all cancers combined from 1991 to 2004 in the overall US population, with remarkable declines in mortality for the top 3 causes of cancer death in men (lung, colorectal, and prostate cancer) and 2 of the top 3 cancers in women (breast and colorectal cancer). However, not all segments of the population have benefited equally from this progress, and evidence suggests that some of these differences are related to lack of access to health care. Lack of adequate health insurance appears to be a critical barrier to receipt of appropriate health care services. This article provides an overview of systems of health insurance in the United States, demographic and socioeconomic characteristics associated with health insurance coverage, and economic burdens related to health care among individuals and families. This article also presents data on the association between health insurance status and screening, stage at diagnosis, and survival for breast and colorectal cancer based on analyses of the National Health Interview Survey and the National Cancer Data Base. Although this article focuses on associations between health insurance and cancer care utilization and outcomes, it is important to recognize that barriers to receipt of optimal cancer care are complex and involve patient‐level, provider, and health system factors. Evidence presented in this paper suggests that addressing insurance and cost‐related barriers to care is a critical component of efforts to ensure that all Americans are able to share in the progress that can be achieved by access to high‐quality cancer prevention, early detection, and treatment services.

Tobacco Control in the United States—Recent Progress And Opportunities

Effective tobacco control efforts have resulted in substantial declines in tobacco use and tobacco‐related cancer deaths in the United States. Nearly 40% of reductions in male lung cancer deaths between 1991 and 2003 can be attributed to smoking declines in the last half century. Nevertheless, tobacco use still remains the single, largest preventable cause of disease and premature death in the United States. Each year, smoking and exposure to secondhand smoke result in nearly half a million premature deaths of which nearly one‐third are due to cancer. In a previous report, we described youth and adult smoking prevalence and patterns and discussed policy measures that had proven effective in comprehensive tobacco control. In this report, we update trends in youth and adult smoking prevalence. We find that while adult smoking prevalence has declined overall, socioeconomic gradients in smoking still persist within race and ethnic subgroups. In addition, we describe the diffusion of tobacco‐control strategies at the national, state, and community level. Although recent developments, such as the Food and Drug Administrations (FDA) regulation of tobacco products, hold promise for tobacco control, there continues to be a need for broader dissemination of sustainably funded comprehensive national and state tobacco‐control programs. CA Cancer J Clin 2009;59:352–365.

Association of Insurance Status and Age With Cervical Cancer Stage at Diagnosis: National Cancer Database, 2000–2007

OBJECTIVES We examined the relationship of age at diagnosis and insurance status with stage among cervical cancer patients aged 21 to 85 years. METHODS We selected data on women (n = 69 739) diagnosed with invasive cervical cancer between 2000 and 2007 from the National Cancer Database. We evaluated the association between late stage (stage III/IV) and both insurance and age, with adjustment for race/ethnicity and other sociodemographic and clinical factors. We used multivariable log binomial models to estimate risk ratios (RRs) and 95% confidence intervals (CIs). RESULTS The proportion of late-stage disease increased with age: from 16.53% (21-34 years) to 42.44% (≥ 70 years). The adjusted relative risk of advanced-stage disease among women aged 50 years and older was 2.2 to 2.5 times that of patients aged 21 to 34 years. Uninsured (RR = 1.44; 95% CI = 1.40, 1.49), Medicaid (RR = 1.37, 95% CI = 1.34, 1.41), younger Medicare (RR = 1.12, 95% CI = 1.06, 1.19), and older Medicare (RR = 1.20, 95% CI = 1.15, 1.26) patients had a higher risk of late-stage disease than did privately insured patients. CONCLUSIONS Screening should be encouraged for women at high risk for advanced-stage disease.

Cancer‐related risk factors and preventive measures in US Hispanics/Latinos

In this article, we provide prevalence data on major cancer‐related risk factors, early detection testing, and vaccination among Hispanics using nationally representative surveys. Compared with non‐Hispanic whites, Hispanic adults are less likely to be current smokers (13% vs 22%) or frequent alcohol drinkers, but they are more likely to be obese (32% vs 26%) and to have lower levels of mammography use within the past year (46% vs 51%), colorectal screening as per recommended intervals (47% vs 61%), and Papanicolaou (Pap) test use within the past 3 years (74% vs 79%). Within the Hispanic population, the prevalence of these risk factors and early detection methods substantially vary by country of origin. For example, Cuban men (20.7%) and Puerto Rican men (19%) had the highest levels of current smoking than any other Hispanic subgroups, while Mexican women had the lowest levels of mammogram use (44%) and Pap test use (71%). Hispanic migrants have a higher prevalence of hepatitis B virus and Helicobacter pylori, which cause liver and stomach cancer, respectively. Among Hispanic adolescents, tobacco use (eg, 20.8% use of any tobacco products), alcohol use (42.9%), and obesity (23.2%) remain highly prevalent risk factors. Although 56% of Hispanic adolescents initiate human papillomavirus vaccination, only 56% of them completed the 3‐dose series. Differences in risk factors and early detection testing among Hispanic groups should be considered in clinical settings and for cancer control planning. CA Cancer J Clin 2012;.

Trends in colorectal cancer screening with home‐based fecal occult blood tests in adults ages 50 to 64 years, 2000‐2008

National surveys have reported declines in rates of home‐based fecal occult blood test (FOBT) screening for colorectal cancer (CRC) in the last decade. However, socioeconomic status (SES) and racial/ethnic differences in FOBT trends and their changes relative to endoscopic CRC screening have not been evaluated.

Progress and opportunities in tobacco control.

Much progress has been made in reducing tobacco use in the United States. Despite the continuing challenges of tobacco control and the massive burden of illness, death, and economic costs caused by tobacco products, there are now unprecedented opportunities to prevent and treat tobacco dependence through a combination of interventions that have proven effective at both the population and individual levels. This report briefly reviews population trends in tobacco use by youth and adults, describes some of the policy measures that have proven effective in comprehensive tobacco control, and discusses the role of clinicians in the diagnosis and treatment of tobacco dependence in patients.

Use of Sunless Tanning Products Among US Adolescents Aged 11 to 18 Years

OBJECTIVE To describe the prevalence and correlates of the use of sunless tanning products among US adolescents and their association with UV radiation exposure behaviors, including indoor tanning, sunburn experiences, and use of sunscreen while outdoors. DESIGN Telephone-based, random-digit-dialed, cross-sectional survey conducted from July 1 through October 30, 2004. SETTING Telephone-accessible households with resident adolescents living with parents or caregivers in the mainland United States. PARTICIPANTS Nationally representative, population-based sample of 1600 adolescents aged 11 to 18 years and their caregivers. MAIN OUTCOME MEASURE Prevalence of recent (past-year) use of sunless tanning products and UV radiation exposure behaviors. RESULTS The prevalence of self-reported use of sunless tanning products in the past year among US adolescents was 10.8%. Adolescent users of these products were more likely to be older and female, to perceive a tanned appearance as desirable, to have a parent or caregiver who used sunless tanning products, and to hold positive beliefs or attitudes about these products. Use of sunless tanning products was independently associated with indoor tanning and higher frequency of sunburn but not with use of sunscreen. CONCLUSIONS Among US adolescents, 10.8% used sunless tanning products in the past year; this practice was associated with risky UV radiation exposure-related behaviors. Adolescents, therefore, must be educated about these products and the importance of avoiding indoor tanning and practicing sun-protective behaviors.

The association between state mandates of colorectal cancer screening coverage and colorectal cancer screening utilization among US adults aged 50 to 64 years with health insurance

BackgroundSeveral states in the US have passed laws mandating coverage of colorectal cancer (CRC) screening tests by health insurance plans. The impact of these state mandates on the use of colorectal cancer screening has not been evaluated among an age-eligible target population with access to care (i.e., health care insurance coverage).MethodsWe collected information on state mandates implemented by December 31, 2008 and used data on insured adults aged 50 and 64 years from the Behavioral Risk Factor Surveillance System between 2002 and 2008 to classify individual-level exposure to state mandates for at least 1 year. Multivariate logistic regression models (with state- and year- fixed effects, and patient demographic and socioeconomic characteristics) were used to estimate the effect of state mandates on recent endoscopy screening (either flexible sigmoidoscopy or colonoscopy during the past year).ResultsFrom 1999-2008, twenty-two states in the US, including the District of Columbia passed comprehensive laws requiring health insurance coverage of CRC screening including endoscopy tests. Residence in states with CRC screening coverage mandates in place for at least 1 year was associated with a 1.4 percentage point increase in the probability of utilization of recent endoscopy (i.e., 17.5% screening rates in those with mandates versus 16.1% in those without, Adjusted OR = 1.10, 95% CI: 1.02 - 1.20, p = 0.02).ConclusionsThe findings suggest a positive, albeit small, impact of state mandates on the use of recent CRC screening endoscopy among the target eligible population with health insurance. However, more research is needed to evaluate potential effects of mandates across health insurance types while including controls for other system-level factors (e.g. endoscopy and primary care capacity). National health insurance reform should strive towards a system that expands access to recommended CRC screening tests.

Physician sun protection counseling: Prevalence, correlates, and association with sun protection practices among US adolescents and their parents, 2004

OBJECTIVE To assess the population prevalence and correlates of ever receiving physician advice to practice sun protection (i.e. sun protection counseling) and whether such counseling is associated with sun protection behaviors in adolescents and their parents. METHOD Analysis of a nationally representative cross-sectional telephone survey of ultraviolet radiation exposure behaviors among US adolescents ages 11 to 18 and their parents, conducted between August and November 2004. RESULTS Forty-four percent of US adolescents and their parents reported physician sun protection counseling. Counseling was more frequently reported by adolescents whose parents were also counseled, reported other sun protection information sources (skin cancer prevention media messages and school sun safety messages), had first degree relatives with skin cancer, and were white, non-Hispanic. Counseling was positively associated with regular sunscreen use, appropriate sunscreen application practices, and intermittent hat use, but not with other recommended behaviors. Sunscreen use rates were generally higher among adolescents reporting several sun protection information sources (counseling, media and school messages) than those with combinations of two or fewer of these sources. CONCLUSIONS The role of physicians, either independently or in concert with other information sources, should be explored in strategies promoting primary skin cancer prevention behaviors among adolescents and parents.