Robert R. German

The Epidemiology of Diabetes and Pregnancy in the U.S., 1988

OBJECTIVE To determine the prevalence of pregnancy complicated by diabetes in a representative sample of the U.S. population. RESEARCH DESIGN AND METHODS We analyzed data from a multistaged cross-sectional probability sample of live births recorded in the U.S. in 1988 for women 15–49 years of age. The main outcome measure was pregnancy complicated by diabetes. RESULTS Diabetes was present in congruent to 154,000 (4%) of all pregnancies in the U.S. Gestational diabetes mellitus (GDM) accounted for 135,000 of such pregnancies (88%), non-insulin-dependent diabetes mellitus (NIDDM) for 12,000 (8%), and insulin-dependent diabetes mellitus for 7,000 (4%). On average, the mothers with NIDDM (29.6 years) and GDM (29.3 years) were older than mothers whose pregnancies were not complicated by diabetes (26.2 years; P < 0.05). In multivariate analyses, the odds of having a pregnancy complicated by GDM increased significantly with maternal age and body mass index. CONCLUSIONS Pregnancy is complicated by diabetes more often than was previously believed. More frequent testing may further increase the apparent prevalence of GDM.

Obesity Is Negatively Associated with Prostate-Specific Antigen in U.S. Men, 2001-2004

Background: Recent studies have shown a negative association between body mass index (BMI) and prostate-specific antigen (PSA), a commonly used serum marker for the detection and diagnosis of prostate cancer. We have examined the association between several anthropometric measures and PSA in a nationally representative sample of men. Methods: We analyzed data from the 2001-2004 National Health and Nutrition Examination Survey. Participants in this study were men ages ≥40 years without previously diagnosed prostate cancer who had PSA measured. Height, weight, waist circumference, BMI, triceps skinfold, subscapular skinfold, and calculated total body water were examined categorically by quintiles using multiple linear regression models. All tests of significance were two sided. Results: Among white men, we report a trend for decreasing PSA with increasing weight, BMI, waist circumference, triceps skinfold thickness, and calculated total body water. Among Mexican American men, we found a trend for decreasing PSA with increasing BMI, and among black men we found a trend for decreasing PSA with increasing triceps thickness. None of the interaction terms between race/ethnicity and any of the anthropometric measures were statistically significant. Controlling for age and race/ethnicity in the multiple linear regression model, we found moderate declines in PSA with a 1 SD increase in BMI [5.9% decrease (95% confidence interval, −9.0% to −2.8%) in geometric mean PSA per 5.2-unit increase], weight [5.9% decline (−8.8% to −2.8%) per 17.7-kg increase], waist circumference [6.6% decline (−9.4% to −3.6%) per 13.4-cm increase], triceps skinfold [5.4% decline (−8.9% to −1.8%) per 6.4-mm increase], and calculated total body water [5.7% decline (−8.9% to −2.4%) per 6.5-liter increase]. Conclusion: Our population-based, nationally representative results expand the validity of previous studies on obesity and PSA. Higher weight, BMI, waist circumference, triceps skinfold, and total body water are associated with moderately lower PSA values. A prospective study is needed to verify whether this association affects the accuracy of the PSA test in obese men. (Cancer Epidemiol Biomarkers Prev 2007;16(1):70–6)

The accuracy of cancer mortality statistics based on death certificates in the United States

BACKGROUND One measure of the accuracy of cancer mortality statistics is the concordance between cancer defined as the underlying cause of death from death certificates and cancer diagnoses recorded in central, population-based cancer registries. Previous studies of such concordance are outdated. OBJECTIVE To characterize the accuracy of cancer mortality statistics from the concordance between cancer cause of death and primary cancer site at diagnosis. DESIGN Central cancer registry records from California, Colorado, and Idaho in the U.S. were linked with state vital statistics data and evaluated by demographic and tumor information across 79 site categories. A retrospective arm (confirmation rate per 100 deaths) compared death certificate data from 2002 to 2004 with cancer registry diagnoses from 1993 to 2004, while a prospective arm (detection rate per 100 deaths) compared cancer registry diagnoses from 1993 to 1995 with death certificate data from 1993 to 2004 by International Statistical Classification of Diseases and Related Health Problems (ICD) version used to code deaths. RESULTS With n=265,863 deaths where cancer was recorded as the underlying cause based on the death certificate, the overall confirmation rate for ICD-10 was 82.8% (95% confidence interval [CI], 82.6-83.0%), the overall detection rate for ICD-10 was 81.0% (95% CI, 80.4-81.6%), and the overall detection rate for ICD-9 was 85.0% (95% CI, 84.8-85.2%). These rates varied across primary sites, where some rates were <50%, some were 95% or greater, and notable differences between confirmation and detection rates were observed. CONCLUSIONS Important unique information on the quality of cancer mortality data obtained from death certificates is provided. In addition, information is provided for future studies of the concordance of primary cancer site between population-based cancer registry data and data from death certificates, particularly underlying causes of death coded in ICD-10.

Trends in Diabetes and Diabetic Complications, 1980–1987

OBJECTIVE Although diabetes is a major source of morbidity and mortality in the United States, only recently has a unified national surveillance system begun to monitor trends in diabetes and diabetic complications. RESEARCH DESIGN AND METHODS We established a diabetes surveillance system using data for 1980–1987 from vital records, the National Health Interview Survey, the National Hospital Discharge Survey, and the Health Care Financing Administrations records to examine trends in the prevalence and incidence of diabetes, diabetes mortality, hospitalizations, and diabetic complications. RESULTS From 1980 through 1987, the number of individuals known to have diabetes increased by 1 million—to 6.82 million. Age-standardized prevalence for diabetes increased 9% during this period, from 25.4 to 27.6/1000 U.S. residents (P = 0.03). The incidence of diabetes increased among women (P = 0.003), particularly among those > 65 yr old (P = 0.02). Age-standardized mortality rates (for diabetes as either an underlying or contributing cause) per 100,000 individuals with diabetes declined 12%, from 2350 to 2066. Annual mortality rates from stroke (as an underlying cause and diabetes as a contributing cause) and diabetic ketoacidosis declined 29% (P = 0.003) and 22% (P < 0.001), respectively. During these 8 yr, hospitalization rates for major CVD and stroke (as the primary diagnoses and diabetes as a secondary diagnosis) increased 34% (P = 0.006) and 38% (P = 0.01), respectively. Also during this period, hospitalization rates increased 21% for diabetic ketoacidosis (P = 0.01) and 29% for lower-extremity amputations (P = 0.06). From 1982 through 1986, treatment for end-stage renal disease related to diabetes increased > 10% each year (P < 0.001). The prevalence of diagnosed diabetes was nearly twice as high in blacks as in whites (P = 0.04). Blacks also had increased rates of lower-extremity amputation (P = 0.02), diabetic ketoacidosis (P < 0.001), and end-stage renal disease (P = 0.01). CONCLUSIONS Diabetes surveillance data will be useful in planning, targeting, and evaluating public health efforts designed to prevent and control diabetes and its complications.

Descriptive epidemiology of colorectal cancer in the United States, 1998-2001.

BACKGROUND. Colorectal cancer (CRC) incidence rates are increasing among persons younger than 50 years of age, a population routinely not screened unless an individual has a high risk of CRC. This population-based study focuses primarily on describing the CRC burden for persons in this age group. METHODS. The data used for this study were derived from the National Program of Cancer Registries (NPCR) and Surveillance, Epidemiology, and End Results (SEER) surveillance systems. Age-adjusted incidence rates, rate ratios, and their corresponding 95% confidence intervals were calculated. RESULTS. CRC is ranked among the top 10 cancers occurring in males and females aged 20–49 years regardless of race. Persons younger than 50 years were more likely to present with less localized and more distant disease than do older adults. Among younger adults, age-adjusted incidence rates for poorly differentiated cancers were twice as high as rates for well-differentiated cancers. Incidence rates for poorly differentiated cancers were 60% higher than that for welldifferentiated cancers diagnosed in older adults. Rates were significantly higher for blacks and significantly lower for Asians/Pacific Islanders when compared with that for whites for the most demographic and tumor characteristics examined. CONCLUSIONS. This study confirms the findings of previous population-based studies suggesting that younger patients present with more advanced disease than do older patients. This study also identifies racial and ethnic disparities in CRC incidence in this population. These findings suggest the need for additional studies to understand the behavior and etiology of CRC in blacks. Cancer

Factors associated with initial treatment and survival for clinically localized prostate cancer: results from the CDC-NPCR Patterns of Care Study (PoC1)

BackgroundDespite the large number of men diagnosed with localized prostate cancer, there is as yet no consensus concerning appropriate treatment. The purpose of this study was to describe the initial treatment patterns for localized prostate cancer in a population-based sample and to determine the clinical and patient characteristics associated with initial treatment and overall survival.MethodsThe analysis included 3,300 patients from seven states, diagnosed with clinically localized prostate cancer in 1997. We examined the association of sociodemographic and clinical characteristics with four treatment options: radical prostatectomy, radiation therapy, hormone therapy, and watchful waiting. Diagnostic and treatment information was abstracted from medical records. Socioeconomic measures were derived from the 2000 Census based on the patients residence at time of diagnosis. Vital status through December 31, 2002, was obtained from medical records and linkages to state vital statistics files and the National Death Index. Multiple logistic regression analysis and Cox proportional hazards models identified factors associated with initial treatment and overall survival, respectively.ResultsPatients with clinically localized prostate cancer received the following treatments: radical prostatectomy (39.7%), radiation therapy (31.4%), hormone therapy (10.3%), or watchful waiting (18.6%). After multivariable adjustment, the following variables were associated with conservative treatment (hormone therapy or watchful waiting): older age, black race, being unmarried, having public insurance, having non-screen detected cancer, having normal digital rectal exam results, PSA values above 20, low Gleason score (2-4), comorbidity, and state of residence. Among patients receiving definitive treatment (radical prostatectomy or radiation therapy), older age, being unmarried, PSA values above 10, unknown Gleason score, state of residence, as well as black race in patients under 60 years of age, were associated with receipt of radiation therapy. Overall survival was related to younger age, being married, Gleason score under 8, radical prostatectomy, and state of residence. Comorbidity was only associated with risk of death within the first three years of diagnosis.ConclusionsIn the absence of clear-cut evidence favoring one treatment modality over another, it is important to understand the factors that inform treatment selection. Since state of residence was a significant predictor of both treatment as well as overall survival, true regional differences probably exist in how physicians and patients select treatment options. Factors affecting treatment choice and treatment effectiveness need to be further explored in future population-based studies.

Case completeness and data accuracy in the Centers for Disease Control and Prevention's National Program of Cancer Registries

Issues of case completeness (CC) and data quality within the National Program of Cancer Registries (NPCR)‐Cancer Surveillance System (NPCR‐CSS) are assessed in part by the NPCR Technical Assistance and Audit Program (NPCR‐TAA). In addition, the NPCR Annual Program Evaluation Instrument (NPCR‐APEI) provides information about NPCR‐supported central cancer registries (CCRs). The current report includes a unique, national‐level analysis of NPCR‐TAA results linked with NPCR‐APEI data and other covariates.

Incidence of Testicular Cancer in the United States, 1999-2004

Testicular cancer is rare but primarily affects young men. To characterize the current incidence of testicular cancer in the United States, U.S. Cancer Statistics data from 1999 through 2004 were examined. Age-adjusted (2000 U.S. standard) incidence rates were calculated for seminoma and nonseminoma testicular germ cell tumors (TGCTs). Hispanic men had the largest increase in incidence rates for nonseminomas, followed by non-Hispanic White men (annual percentage change of 3.2% and 1.9%, respectively, p < .05). Nonseminomas peaked at a younger age for Hispanic, American Indian/Alaska Native (AIAN), and Asian/Pacific Islander (API) men. Whereas 9.6% of TGCTs were diagnosed at a distant stage in non-Hispanic White men, more Hispanic (16.1%), Black (13.8%), AIAN (16.8%), and API (14.9%) men with TGCTs were diagnosed with distant stage. Monitoring incidence rates for rare cancers by race/ethnicity has improved with national population-based cancer registry coverage. Disparities in diagnosis stage have implications for effective treatment of TGCTs.

The impact of National Death Index linkages on population-based cancer survival rates in the United States.

BACKGROUND In order to ensure accurate survival estimates, population-based cancer registries must ascertain all, or nearly all, patients diagnosed with cancer in their catchment area, and obtain complete follow-up information on all deaths that occurred among registered cancer patients. In the US, linkage with state death records may not be sufficient to ascertain all deaths. Since 1979, all state vital statistics offices have reported their death certificate information to the National Death Index (NDI). OBJECTIVE This study was designed to measure the impact of linkage with the NDI on population-based relative and cancer cause-specific survival rates in the US. METHODS Central cancer registry records for patients diagnosed 1993-1995 from California, Colorado, and Idaho were linked with death certificate information (deaths 1993-2004) from their individual state vital statistics offices and with the NDI. Two databases were created: one contained incident records with deceased patients linked only to state death records and the second database contained incident records with deceased patients linked to both state death records and the NDI. Survival estimates and 95% confidence intervals from each database were compared by state and primary site category. RESULTS At 60 months follow-up, 42.1-48.1% of incident records linked with state death records and an additional 0.7-3.4% of records linked with the NDI. Survival point estimates from the analysis without NDI were not contained within the corresponding 95% CIs from the NDI augmented analysis for all sites combined and colorectal, pancreas, lung and bronchus, breast, prostate, non-Hodgkin lymphoma, and Kaposi sarcoma cases in all 3 states using relative survival methods. Additional combinations of state and primary site had significant survival estimate differences, which differed by method (relative versus cause-specific survival). CONCLUSION To ensure accurate population-based cancer survival rates, linkage with the National Death Index to ascertain out of state and late registered deaths is a necessary process for US central cancer registries.

Diabetes-Associated Mortality in Native Americans

OBJECTIVE— To describe diabetes-associated mortality among Native Americans. RESEARCH DESIGN AND METHODS— In this population-based study, we analyzed diabetes-associated mortality data from the IHS and the NCHS. We also examined diabetes data from the 1986 NMFS. RESULTS— IHS area-specific diabetes mortality rates for 1984–1986 ranged from 10 to 93/100,000, compared with 15/100,000 for the total U.S. population. NCHS data for the same period listed diabetes as the underlying cause of 708 deaths among Native Americans and the contributory cause of 1252 deaths; 63% of the latter deaths were attributable to circulatory diseases. The 1986 NMFS demonstrated that Native American heritage is underreported by 65% on death certificates. Using deaths identified as Native American by NMFS, the age-adjusted mortality rate for diabetes as the underlying cause for Native Americans (96/100,000) was 4.3 times that for whites and two times that for blacks. Where diabetes was a contributory cause of death, the mortality rate for Native Americans (264/100,000) was 3.7 times that for whites and 2.4 times that for blacks. CONCLUSIONS— The excessive diabetes-associated mortality among Native Americans is consistent with other indicators of the magnitude of the diabetes problem in this population. Further epidemiological research and expanded diabetes control interventions are needed.