The Gender Gap in Heart Disease in Eastern Europe

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Ora Paltiel, MD, MSc Braun School of Public
Health Community MedicineHebrew University of
Jerusalem Hadassah Medical Organization Israel
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Epidemiological ReasoningUsing Cancer Statistics
Or, how to use descriptive statistics to raise
hypotheses
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Issues to be discussed

• Validity of data
• Reporting
• Confounding
• Effect modification

• Using Descriptive Data
• Burden of Disease
• Planning
• Hypothesis raising
• Measuring progress

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What are the objectives of epidemiology?
1. To determine the extent of disease (states of
health) and/or behaviors in the community. 2. To
identify the etiology or the cause/s of a disease
and the risk factors - that is, factors that
increase a persons risk for a disease. 3. To
study the natural history and prognosis of
disease.
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Objectives of epidemiology
4. To evaluate new preventive and therapeutic
measures and new modes of health care
delivery. 5. To provide the foundation for
developing public policy and regulatory decisions
relating to public health problems.
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When we measure, we know better
- Center for Disease Control (CDC), Atlanta,
Georgia,USA
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The epidemiological tool-box
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Kaposi sarcoma in New York
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The context of disease reporting
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Lowest cancer death rate In the Former Yugoslav
Republic of Macedonia, only 6 people per 100,000
of population die from cancer each year
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Lifetime risk of developing breast cancer,
1940-1987
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Lifetime risk of developing breast cancer,
1940-1987 contd

• YEAR ONE IN.
• 1940 20
• 1950 15
• 1960 14
• 1970 13
• 1980 11
• 1987 9
• Source American Cancer Society, 1991

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Descriptive epidemiology - hypothesis raising
rarely provides enough evidence for causation

• Person characteristics for study include
• Age
• Gender
• Religion
• Marital status
• Ethnicity
• Occupation
• Socio-economic class
• Heredity vs. Environment

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Age-specific rates of Breast Cancer Mortality
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Population Pyramids 1998
Russian Federation
Israel
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Trends of Cervical Cancer Mortality in Europe and
North America
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Age-standardized cervical cancer death rates (and
95 confidence intervals) per 100 000 women in
urban Canada by neighbourhood income quintile
from 1971 to 1996. Q1 richest Q5 poorest.
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Place and time

• Time trends - raise hypotheses regarding
  environmental factors or results of medical care
• Geographic variation - on small large scale,
  environmental ? genetic factors
• Study of migrants important for separating
  environmental from genetic factors

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Numbers of cases of cancer at 16 anatomical sites
in developed and in developing countries, with
relative ranks
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Lung Cancer Mortality for Women 1998, ASR/100000
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Lung Cancer Mortality for men 1998, ASR/100000
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Age-adjusted cancer death rates, males by site,
US, 1930-1996
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Age-adjusted cancer death rates, females by site,
US, 1930-1996
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Estimated annual percent changes in mortality
from all types of cancer in the US over 2 periods
1973-1990 and 1991-1995, according to age group
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Place and time contd

• Japanese colon cancer incidence
• Japan Hawaii California
• - ? rate is affected by age at immigration
• - for breast cancer 2 generations required for ?
  rate

High
Intermediate
Low
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Biases in migrant studies

• 1) Different reporting
• 2) Different diagnostic criteria
• 3) Migrants are selected group

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Where does evidence come from?
Clinical observation
Descriptive data
Hypothesis raising
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Hypothesis raising
Clinical observation
Descriptive data
Analytical studies
Hypothesis testing