Evaluation and Implementation of State Comprehensive Cancer Control Plans: Evolving Lessons

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Evaluation and Implementation of State
Comprehensive Cancer Control Plans Evolving
Lessons

• APHA 2005 Annual Meeting
• Epidemiology Section
• Session 3187.0
• 1230200 PM
• Monday, December 12, 2005

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Assessing cancer burdenEstimating and utilizing
prevalence

• Presented by
• Judith B. Klotz, DrPH
• UMDNJ-School of Public Health

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• Co-authors of this presentation include
• Stanley H. Weiss, MD
• Xiaoling Niu, MS
• Jung Y. Kim, MPH
• Daniel M. Rosenblum, PhD

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Context Capacity and Needs Assessment at County
Level

• Focus on seven NJ-CCCP priority cancers
• Breast, Cervical, Colorectal, Lung, Melanoma,
  Oral/Oropharyngeal, Prostate
• Need for estimates of burden of cancer in the
  population
• Prevalence number of people living with a
  disease at a point in time
• Cancer prevalence estimates are useful
  supplements to incidence and mortality
  statistics, and help determine the level of
  cancer control efforts needed

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Uses of Prevalence Data Include

• Assessing current burden of disease
• Predicting future burden of disease
• Planning of health services
• Allocation of medical resources
• Planning and administering health care facilities
• Guiding health care research programs

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A Limitation of Incidence and Mortality Statistics

• Adjusted rates do not reflect actual burden of
  disease or number of persons affected

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Institute of Medicine (IOM)2006 Report on Cancer
Survivors

• Over 10,000,000 prevalent cases today in U.S.
• Dearth of coordinated clinical and support
  follow-up services for patients and their families

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IOM Report Follow up needs for patients and
families

• Rehabilitation and quality-of-life issues
• Psychological stresses
• e.g. potential for recurrence
• Acute or chronic pain or other side effects from
  cancer treatment
• Risks of additional cancer from radiation/
  chemotherapy
• Needs for continuing treatment and/or screening
• Insurance issues

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Types of Prevalence

• Prevalence (count) Number of people living with
  the disease at a point in time
• Prevalence rate Number of prevalent
  casesdivided by the total population

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Types of Prevalence, cont.

• Complete Prevalence
• Usually preferred for cancer
• Includes all survivors, regardless of years since
  diagnosis
• Rationale long-term needs of patients and
  families for medical and psychosocial services
• Limited Duration Prevalence
• Includes those who were diagnosed within
  specified number of years (e.g., 2, 5, 10, 20)
• So does NOT include those who survive after the
  number of years at which follow-up is truncated

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Typical Sources of Prevalence Data

• Population Surveys
• Estimation from combination of incidence and
  survival data
• Cannot simply combine mortality and incidence
  data in a particular year because they pertain to
  different, specific persons
• Most people who die in a particular year were
  diagnosed in an earlier year

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Current Availability ofTotal Prevalence Estimates

• Conducted by NCI for U.S. based on longest cancer
  registries and complex modeling
• Connecticut Tumor Registry since 1935
• New models developed in Italy and adapted by NCI
• New SEERStat program
• Newly available as of August 2005 (after C/NA was
  completed)
• Provides counting method for limited duration
  prevalence
• Years since diagnosis depend on inception of
  state cancer registry
• New utility, COMPREV estimates complete
  prevalence from limited-duration prevalence

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Capacity and Needs AssessmentPrevalence
Estimates for Counties

• Basic method for C/NA, 20032004
• This method was reviewed and approved by the
  Evaluation Committee of Governors Task Force
• Use the ratio of prevalence rate to crude
  incidence rate from national (NCI SEER) data,
• By specific cancer
• By gender
• Apply this ratio to county-specific crude
  incidence rate
• Wide variability among counties expected due to
  variations in population size and demographics

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Capacity and Needs AssessmentPrevalence
Estimates for Counties

• Source Data
• a. Total populations for each county (by
  gender),from the 2000 Census
• b. Incidence counts for 19962000 for each
  county, as provided by the NJ State Cancer
  Registry
• These were used to calculate crude incidence
  rate, separately for each gender
• Crude incidence rate x 100,000

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Simplifying Assumptions

• County survival rates assumed to resemble
  national survival rates by gender, for each
  cancer, whereas these may in fact vary
• Migration in and out of counties assumed not to
  affect prevalence counts, whereas migration after
  diagnosis could alter the true number of affected
  people still living in a given county

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Simplifying Assumptions, cont.

• Racial and ethnic distributions assumed not to
  alter county survival rates, whereas these
  demographic differences could affect numbers of
  survivors in any county
• Crude incidence is approximated by 19962000
  data, whereas current incidence may now differ

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Prevalence to Incidence Ratios

• Of the prevalence to incidence ratios forthe 7
  NJ-CCCP priority cancers,
• Lowest ratio Lung cancer (males) 1.4
• Highest ratio Cervical cancer 17.0
• Interpretation There are about 17 times as
  many living women who have been diagnosed with
  cervical cancer as have been newly diagnosed
  during one year.
• Ratio of national estimated complete prevalence
  rate to national incidence rate

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Calculated from NCI Data Prevalence/Crude
Incidence Ratios
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SEERStat Prevalence Estimates for NJ and its
Counties

• Calculated a 20-year duration limited prevalence
  
• NJ State Cancer Registry began 1979, so that
  there is data for more than 20 years
• Data currently available through 2003
• Used January 1, 1999 as the sample point in time
• These prevalence statistics have not yet been
  published by NJ Dept of Health and Senior Services

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SEERStat Prevalence Estimates for NJ and its
Counties

• For long-survival cancers,SEERStat count
  estimates were markedly lower than C/NA complete
  prevalence estimates
• e.g. Limited/complete ratio for cervical cancer
• State 0.64
• Counties 0.560.84
• Note It is to be expected that estimates for
  counties will vary markedly from each other

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SEERStat Prevalence Estimates for NJ and its
Counties

• For short-survival cancers,SEERStat limited
  duration estimates were in closer agreement with
  C/NA complete prevalence estimates, both
  statewide and for many counties
• e.g. Limited/complete ratio for lung cancer
• State 1.1
• Counties 0.931.3

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Ratios of Estimate Counts for SEERStat Limited
Prevalence toC/NA Complete Prevalence
Results discussed above are highlighted in yellow
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Comparison with SEERStat Estimates for NJ
Counties, cont.

• Gender differences in prevalent case estimates
  for colorectal cancer were shown by C/NA method
  but not SEERStat
• perhaps related to longer lifespan of women
• Limitations of prevalence estimates currently
  available from State Cancer Registries using
  SEERStat
• Duration depends on year of inception of Registry
• For 15 states less than 10 years available

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Comparisons of Estimated Counts Some Examples
Male female combined
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Comparison with SEERStat Estimates for NJ
Counties, cont.

• Future analyses
• We anticipate using SEERs new COMPREV to
  estimate Complete prevalence from the
  Limited-Duration prevalence, and then to compare
  these results to the C/NA method used in 20032004

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Use of County Prevalence Estimates to date

• County cancer control planners and county cancer
  coalitions have found prevalence estimates useful
  for
• Estimation of relative burden of disease among
  county populations of different cancers
• Recommendations for priority actions

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County Use of Prevalence Data in Assessing Needs
for Cancer Control

• An Example
• "The four most prevalent NJ-CCCP priority cancers
  in Somerset County are breast, prostate,
  colorectal cancer, and melanoma.... and the
  goals and strategies in the NJ-CCCP that are of
  highest priority for Somerset County are outlined
  below for each of these four cancers.
• Source Somerset County, Capacity and Needs
  Assessment Executive Summary 2003

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Acknowledgments and Websites

• We acknowledge
• Cancer Epidemiology Services, New Jersey
  Department of Health and Senior Services
  Lisa Roché, PhD
• Betsy Kohler, MS, CTR
• County Evaluators of the NJ-CCCP Capacity and
  Needs Assessment
• NCI SEERStat websitehttp//srab.cancer.gov/comp
  rev/
• Evaluation Committee websitehttp//www.umdnj.edu
  /evalcweb/