From research to agency reporting: producing an atlas of behavioural cancer risk factors in Ontario


Zeinab El-Masri
Senior Specialist, Knowledge Dissemination & Evaluation, Surveillance & Cancer Registry
Cancer Care Ontario



Figure 1

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The need

An important public health goal is to decrease the prevalence of behavioural risk factors which play a role in the burden of cancer and other chronic diseases.

In Ontario, data on behavioural risk factors are available for large administrative areas from survey data. However, there exists a need for high quality local data to enable public health to better understand heterogeneity in the health of their communities.


A novel solution

Dr. Laura Seliske and Todd Norwood from Cancer Care Ontario collaborated with other cancer surveillance researchers to use advanced spatial analysis methods to produce micro-area estimates of behavioural risk factors from existing survey data. The survey methods are similar to the Behavioural Risk Factor Surveillance System in the U.S. The micro-areas selected, census dissemination areas (DAs), are the smallest geographic unit for which complete census data are available in Canada, with average populations of 400 to 700 people.

In their study, a spatial Bayesian hierarchical model was used to estimate the micro-area prevalence of current smoking and excess body weight within one region in Ontario, allowing the researchers to detect areas, or neighbourhoods, of higher prevalence. The abstract and link to the full manuscript can be found below.



Producing an atlas

These advanced statistical methods were adopted to model small-area risk factor prevalence across all of Ontario to produce an atlas—the first of its kind in Canada—with more than 300 maps. Cancer Risk Factors Atlas of Ontario illustrates the geographic distribution of six behavioural risk factors, by sex and age groups, for neighbourhoods across the province.

Through this atlas, public health in Ontario is empowered with local data to better understand the health of their communities. This information can help support the development of tailored prevention efforts to improve health and reduce local health disparities.



About Cancer Care Ontario
CCO is the Ontario government’s principal advisor on the cancer and kidney care systems, as well as on access to care for key health services. Encompassing Cancer Care Ontario and the Ontario Renal Network, CCO drives continuous improvement in disease prevention and screening, the delivery of care and the patient experience for chronic diseases. It provides tools, resources and evidence-based information to help its healthcare partners improve the delivery of care.

Estimating micro area behavioural risk factor prevalence from large population-based surveys: a full Bayesian approach
BMC Public Health


Background: An important public health goal is to decrease the prevalence of key behavioural risk factors, such as tobacco use and obesity. Survey information is often available at the regional level, but heterogeneity within large geographic regions cannot be assessed. Advanced spatial analysis techniques are demonstrated to produce sensible micro area estimates of behavioural risk factors that enable identification of areas with high prevalence.

Methods: A spatial Bayesian hierarchical model was used to estimate the micro area prevalence of current smoking and excess bodyweight for the Erie-St. Clair region in southwestern Ontario. Estimates were mapped for male and female respondents of five cycles of the Canadian Community Health Survey (CCHS). The micro areas were 2006 Census Dissemination Areas, with an average population of 400–700 people. Two individual-level models were specified: one controlled for survey cycle and age group (model 1), and one controlled for survey cycle, age group and micro area median household income (model 2). Post-stratification was used to derive micro area behavioural risk factor estimates weighted to the population structure. SaTScan analyses were conducted on the granular, postal-code level CCHS data to corroborate findings of elevated prevalence.

Results: Current smoking was elevated in two urban areas for both sexes (Sarnia and Windsor), and an additional small community (Chatham) for males only. Areas of excess bodyweight were prevalent in an urban core (Windsor) among males, but not females. Precision of the posterior post-stratified current smoking estimates was improved in model 2, as indicated by narrower credible intervals and a lower coefficient of variation. For excess bodyweight, both models had similar precision. Aggregation of the micro area estimates to CCHS design-based estimates validated the findings.

Conclusions: This is among the first studies to apply a full Bayesian model to complex sample survey data to identify micro areas with variation in risk factor prevalence, accounting for spatial correlation and other covariates. Application of micro area analysis techniques helps define areas for public health planning, and may be informative to surveillance and research modeling of relevant chronic disease outcomes.

The opinions expressed in this article are those of the authors and may not represent the official positions of NAACCR.


Mesothelioma: A Rare Cancer that Targets Senior Citizens


Rachel Lynch
Press and Media Coordinator



Before the technological revolution and the automation of everything, the world went through an industrialization period. Americans built things with their hands; tradesmen, construction workers, and laborers of all kinds put their blood, sweat, and tears into the creation of buildings, ships, and goods. This time period also aligns with the height of asbestos use. The umbrella term, asbestos, is used to describe six different fibrous minerals and was widely used because of its ability to resist heat, fire, and electricity.

What is Asbestos?

Modern asbestos use in the United States began in the 1930s and peaked during the early 1970s, before federal regulations and alternative options lead to a decline in use. While more than 60 countries around the world have taken actions to prohibit the mineral’s use, the United States has yet to fully implement its own ban. In addition to the United States, the substance is still legal in Russia and Canada. The continued use of the toxic material around the globe is troublesome due to its complications following exposure. Asbestos causes lung cancer, asbestosis, and the rare mesothelioma cancer; in fact the toxin is the only known cause of mesothelioma.


What is Mesothelioma?

Mesothelioma can develop in the lining of the lungs, heart, or abdominal cavity. The most common form is pleural mesothelioma, which affects the lining of the lungs and accounts for 70 to 80 percent of all mesothelioma cases. According to a 2017 report by the Centers for Disease Control, 2,400 to 2,800 people are diagnosed with mesothelioma in the United States each year. The states with the highest number of mesothelioma deaths, from 2001 to 2010, were California, Florida, Pennsylvania, New York, and Texas. Mesothelioma mortality rates are two to four times higher in port cities and parts of “Rust Belt” states.


Mesothelioma and Seniors

Mesothelioma most often affects senior citizens and, unfortunately, there is currently no cure for the disease. Symptoms of the disease can often take decades to develop following initial exposure to the mineral, resulting in a diagnosis much later in life. After such a long period of time has passed, many patients have forgotten about their exposure period and are often uneducated about the potential risks associated with their previous activity.

Unfortunately, while asbestos use has waned in more recent years there has been an increase in the incidence of malignant pleural mesothelioma (MPM) in patients 70 years of age and older. According to the Italian study, patients older than 65 years of age represent 67.4 percent of the registered MPM population, with 26.1 percent of cases diagnosed between 75 and 84-years-old. This population is underserved across the board in the clinical trial realm – geriatric clinical trials are riskier than those for younger patients because they typically have more unrelated health complications. Due to the lack of clinical trials available to identify the best course of treatment for geriatric mesothelioma patients, awareness is the safest way to ensure the best prognosis possible.

With more awareness and education, the hope is that patients will be knowledgeable about their medical history – including any previous asbestos exposure – and initiate conversations with their medical professionals. Starting these conversations early is paramount because catching the disease in its early stages may improve prognosis and treatment options.


How to Prevent Exposure

While much of the exposure occurred years ago when asbestos was not regulated there is still a danger to the public. It has been thirty years since peak asbestos use in the United States, and there are still upwards of 2000 mesothelioma cases diagnosed annually which proves that the US population is still at risk.

Through 2020, the rate of death for malignant mesothelioma in developed countries is expected to increase by 5 to 10 percent annually.

Asbestos can still be found in homes and public buildings built through the 1970s. If your home or office was built during this time period it is in your best interest to have it inspected for asbestos before completing any renovation projects. Insulation, ceiling/floor tiles, cements, caulking, and furnaces are just some examples of the numerous products that once contained asbestos. While current United States federal law requires that newly-manufactured products contain no more than one percent asbestos, products with higher concentrations of the mineral are still lurking in structures across the country. Invest in your future health by ensuring your spaces are free from the carcinogen.


The opinions expressed in this article are those of the authors and may not represent the official positions of NAACCR.


2018 State of Lung Cancer Report


Zach Jump
Director of Epidemiology and Statistics
American Lung Association



Every two and a half minutes someone in the United States will be diagnosed with lung cancer, with an estimated 234,030 new cases in the United States this year. The American Lung Association’s inaugural LUNG FORCE “State of Lung Cancer” 2018 report is the first time that these national and state lung cancer statistics have been analyzed in one report to show how the toll of lung cancer varies across the country and how every state and the nation can do more to protect residents from lung cancer.

“Nationally, the five-year survival rate for lung cancer is 18.1 percent—meaning four out of five people diagnosed will not survive longer than five years,” said American Lung Association National President and CEO Harold P. Wimmer. “More must be done to save lives, and this new report serves as a powerful tool for identifying both needs and opportunities in every state to turn the tide against lung cancer.”

According to Wimmer, in its inaugural year the “State of Lung Cancer” will serve as a baseline for tracking of efforts to defeat lung cancer, and unveil new opportunities to enact change.

“While we have seen some advancements in lung cancer treatment options and a new method of early detection, the burden of lung cancer is not the same everywhere,” said Wimmer. “The ‘State of Lung Cancer’ report makes it clear that as a nation we need to do a better job. Every state needs to make prevention a priority with proven effective policies, and to also ensure screening facilities are available for those eligible for screening, regardless of where you live. This is how we’ll save lives.”

The LUNG FORCE “State of Lung Cancer” 2018 report finds that lung cancer diagnoses and survival rates vary state by state. By better understanding the impact of lung cancer across the nation, efforts and policies can be focused where the needs are greatest. This report ranks each state on the following:

  • Incidence: More than 234,000 people will be diagnosed with lung cancer this year, and the rate of new cases varies greatly by state. The report finds that Utah has the nation’s lowest lung cancer rates while Kentucky has the highest. There are a variety of risk factors associated with lung cancer, including smoking, exposure to radon gas, air pollution and secondhand smoke. Radon testing and mitigation, healthy air protections, and reducing the smoking rate through tobacco tax increases, smokefree air laws and access to comprehensive quit smoking services are all ways to help prevent new lung cancer cases.
  • Survival Rate: Lung cancer is often not caught at an early stage, when it is more likely to be curable. The five-year lung cancer survival rate ranges from 24 percent in New York to 15.9 percent in Louisiana. Only 31 states track this important metric, which should be implemented by all states to enhance monitoring of lung cancer, and help identify how to improve lung cancer survival.
  • Early or Late Diagnosis: People diagnosed at an early stage of lung cancer are five times more likely to survive, but only 18.9 percent of lung cancer cases are diagnosed at an early stage. The percent of cases diagnosed at an early stage—when it is most likely to be curable—was highest for Wyoming at 23.3 percent and lowest for Hawaii and Oregon at 15.0 percent.
  • Screening Centers: The “State of Lung Cancer” finds that those living in states with greater availability of accredited lung cancer screening sites generally have greater early diagnosis and survival of lung cancer. Delaware had the most screening centers per million people at 21.1, while Utah had the fewest centers per million people at 0.7. Raising awareness of screening facilities that perform low-dose CT scans for those eligible can improve patient outcomes.
  • Surgical Treatment: Lung cancer is more likely to be curable if the tumor can be surgically removed, and surgery is more likely to be an option if the diagnosis is made at an early stage before the cancer has spread. Nationally, 21 percent of cases underwent surgery as part of the first course of treatment, ranging from 30.1 percent in Massachusetts to 14.3 percent in Oklahoma.

As the American Lung Association works toward defeating lung cancer, it is the goal of the LUNG FORCE “State of Lung Cancer” report to empower the public with the knowledge and information to appeal to state governors and raise awareness of this deadly disease. The report takes a look at key lung cancer measures to highlight the burden and examine opportunities to better address lung cancer at the state level. The report found that in addition to incidence, early diagnosis, and surgical treatment, it is imperative for states to track survival rate and to identify opportunities to enact lung cancer interventions like decreasing exposure to radon and secondhand smoke, and eliminating tobacco use. This report is both a one-stop resource and rallying cry for state officials, policymakers, researchers and those affected by lung cancer and to emphasize the need for resources and action to decrease the toll of lung cancer across the country.


Click here to view the 2018 State of Lung Cancer Report

The opinions expressed in this article are those of the authors and may not represent the official positions of NAACCR.


HLA-Global gives the California Cancer Registry a 70% Efficiency Boost using Language Engineering

Professor Jon Patrick


Jon Patrick, Ph.D
Health Language Analytics Global



Health Language Analytics Global LogoThe California legislature has enacted a regulation for all cancer service providers to provide electronic reporting to the Cancer Registry. This is expected to significantly increase the number of organisations supplying reports causing a concomitant enlarged volume of reports received annually. Furthermore across the USA there is an ageing CTR workforce without sufficient attraction of younger staff to sustain workforce numbers. This is further compounded by the ageing population who will also add to the increase of the total volume of cancer cases reported annually.

The California Cancer Registry opted to investigate the use of advance Artificial Intelligence methods to automate the identification of cancer reports and coding of the 5 core cancer attributes required from a report of: Site, Histology, Grade, Behaviour and Laterality. The CCR invited Health Language Analytics Global (HLA-G) to demonstrate the application of their technology to this problem in a project running for 15 months over 2016-17. In November 2017 the CCR decided the trials produced sufficiently accurate results to justify going live with the HORIZON system, fixing a date of 26th January 2018. The installed system has automated 100% of Reportability determinations and codifies 70% of reports, with investigations underway to improve this figure.

The success of this technology enables the CCR to investigate the automatic extraction of other content that could increase its contribution to the wider clinical community. The CCR has now requested HLA-G to provide a version that is updated for the 2018 NAACCR reporting specifications. This will be provided in March 2018.

Click here to view the full release

The opinions expressed in this article are those of the authors and may not represent the official positions of NAACCR.

Cancer in Victoria: Statistics and Trends 2016


Helen Farrugia
Victorian Cancer Registry



Latest cancer statistics from the Victorian Cancer Registry

The Victorian Cancer Registry (VCR) plays a vital role in providing cancer data, trends and analysis to stakeholders and the Victorian community. They have recently released their latest cancer statistics report which is a compilation of the latest available Victorian cancer statistics. More than a quarter of century of cancer data are available presented in a variety of reports and graph formats or as data downloads. Included in the report are detailed tables on cancer incidence, mortality and survival, and projections of incidence and mortality to 2031. The early pages of the report include a brief overview of cancer in Victoria in 2016, and a selection of easily interpretable graphs which may be reproduced in your own reports and presentations.

Click here to view the article

The opinions expressed in this article are those of the authors and may not represent the official positions of NAACCR.

Investigation of Ocular Melanoma Incidence, an Aggressive Form of Rare Tumor


Chandrika Rao, PhD.
Director, North Carolina Central Cancer Registry
(NAACCR Communications Committee, NAACCR Narrative Production Editor)



The North Carolina Central Cancer Registry investigated the incidence of a rare form of cancer, ocular melanoma diagnosed among five young women ages 19-31 during 2008-2014. Three of these young women attended the same high school in Huntersville, North Carolina. Ocular melanoma diagnosed clinically and treated with minimal histologic confirmation, for it to strike outside of its usual demographics makes the push to see action so understandable. This ocular melanoma investigation has underscored the importance of our relationship with community physicians and their role in our case ascertainment efforts.

According to the Ocular Melanoma Foundation (, approximately 2,500 adults are diagnosed with ocular melanoma in the United States each year. The incidence is approximately 5 to 7.5 new cases per one million people per year. Males have an increased incidence compared to females, and incidence is highest among people with lighter skin and blue eyes. The incidence rate increases with age and peaks near age 70. Further, among those who develop metastatic ocular melanoma, 90% of patients also develop liver disease. Approximately 50% of ocular melanoma patients will develop metastatic disease within 15 years of the original diagnosis; currently there is no cure for metastatic ocular melanoma.

The CCR did not observe an excess of ocular melanoma cases, and the NC Occupational and Environmental Epidemiology Branch (OEEB) reported that there were no obvious environmental causes identified. Still, perhaps due to the atypical nature of these cases, the investigation was continued to identify potential underlying etiology.

This article details the process taken to ascertain the cases diagnosed and treated in another state. How the process of identifying and following up with physician offices, reviewing hundreds of records received to confirm the diagnosis of ocular melanoma was so time and resource-intensive.

Click here to view the article

The opinions expressed in this article are those of the authors and may not represent the official positions of NAACCR.

CDC/NPCR Survival Supplement in the journal Cancer

Hannah K. Weir, Ph.D, Senior Epidemiologist, Centers for Disease Control and Prevention
(NAACCR Steering Committee Chair)

Cancer published a CDC-led journal supplement focused on cancer survival in the US. This supplement was released on Dec 5, 2017 and all articles are open access. Each of the cancer-specific papers in the supplement includes clinical and cancer control perspectives. These perspectives highlight how clinical practice may have had an impact on population-based cancer survival trends, and how states funded by the Centers for Disease Control and Prevention (CDC)’s National Comprehensive Cancer Control Program can use population-based survival data, along with incidence and mortality data, to inform cancer control activities. The Centers for Disease Control and Prevention helps to support a nationwide network of population-based cancer registries that collect information regarding all patients diagnosed with cancer. These data tell a compelling story about the disproportionate burden of lower cancer survival experienced by vulnerable populations, and can be used by state and national partners to inform cancer control activities.

The supplement includes a forward, The essential role of population-based cancer survival in cancer control in the United States (pages 4961-4962) and an introductory article, Population-based Cancer Survival in the United States (2001-2009): findings from the CONCORD-2 study (pages 4963-4968). The introduction provides survival estimates by race (black, white), state of residence at diagnosis, and stage at diagnosis for nine solid tumors in adults (stomach, colon, rectum, liver, lung, female breast, cervix, ovary and prostate cancer) and for acute lymphoblastic leukemia in children. Data are from 37 statewide cancer registries that participated in the CONCORD-2 study covering 80% of the US population.

One of the original articles may be of particular interest to the cancer surveillance community, The history and use of cancer registry data by public health cancer control programs in the United States (pages 4969-4976). This article covers a broad overview of the history and use of cancer registry data for cancer control programs. This article details how cancer registry data can be used to inform public health action.


The entire Cancer supplement, Population-based Cancer Survival in the United States (2001-2009): findings from
the CONCORD-2 study
can be accessed at:

“The papers in this supplement show large, consistent and persistent racial disparities for many leading cancers diagnosed in the United States. said Hannah Weir, PhD, in CDC’s Division of Cancer Prevention and Control. “These disparities underscore the need for more targeted efforts to ensure that all people receive recommended cancer screening and that all cancer patients receive timely and appropriate high-quality treatment.”

The opinions expressed in this article are those of the authors and may not represent the official positions of NAACCR.

Organic Hazard: Global Mesothelioma Trends and Incidence Rates

Sarah Wallace, Health Advocate,
Mesothelioma + Asbestos Awareness Center


September 26th is Mesothelioma Awareness Day – a day dedicated to spread information on the rarity of the disease, as well as its cause, asbestos. Asbestos exposure counts for nearly 80% of all cases of mesothelioma. While legality varies throughout the world on asbestos, its lasting health impact has been well-known and documented throughout the medical community.

Although legislations throughout the world have regulated or outright banned asbestos, the lasting effects of the former wonder mineral still plague society on a global scale. 55 countries globally have outlawed the usage and importation of the deadly substance; however, many large international players, including the United States, still do not have a ban on asbestos. The biggest threat asbestos poses is the manifestation of mesothelioma, a hyper-aggressive cancer that affects the lining of the organs. With only 10,000 annual cases diagnosed globally, mesothelioma remains a rare killer.

Incidence in North America

Due to the heavy usage of asbestos during periods of industrialization, wartime and building, laborers, veterans and tradesmen have, historically, been the most affected demographic for asbestos-related illness. While male diagnoses still account for the vast majority of mesothelioma cases, female incidence rates have been climbing steadily since the early 1990s. Between 2000-2014, there were 12,045 male diagnoses and only 3,808 female diagnoses – these figures include all races. However, when races are divided, white males account for 11,222 – around 93% of all male cases. White females accounted for 3,476 cases, or 91% of all North American incidences of mesothelioma. While Canada is set on a total ban of asbestos by 2018, both import and usage, the United States and the Environmental Protection Agency are still in the process of evaluating its effects and risk on public health.

International Mesothelioma Rates 

While the majority of Europe has banned asbestos outright, new cases do emerge every year. Great Britain remains the epicenter of mesothelioma incidence in Europe, as the country accounts for highest age-adjusted mortality rate in the world, at 18.36 per million people. Australia ranks as the second highest worldwide, with an incidence rate of of 16.7 per million people. While both nations have made it illegal to import or use asbestos, incidences of mesothelioma still climb. Asia accounts for the most rampant current asbestos usage in the world, with China leading the way at 570,000 tons used per year. Although Asian countries such as China, Indonesia, India and Vietnam utilize the material, statistics related to mesothelioma and asbestos-related illness are not readily available. In some preliminary studies, however, China’s incidence rate for malignant mesothelioma is 1.5 per million – substantially low for its usage for industrial purposes.

The Effects of Asbestos Bans

The move to federally ban asbestos is a relatively recent development, with the Scandinavian countries starting the trend in the early 1980s. Thus, conclusive data regarding the decline of mesothelioma in banned countries is not universally known. However, there have been several studies suggesting rates of asbestos-related cancer seem to be in decline in countries that have outlawed the substance. A collaborative study at Umeå University resulted in the conclusion that workers starting their careers in Sweden, either during or after the ban, have a decreased risk of mesothelioma. Furthermore, the study has shown that the ban has resulted in roughly 12 avoided mesothelioma cases per year. Although the study is restricted only to findings in Sweden, similar results are expected to occur in countries after the ban of asbestos.

What’s the Risk?

Mesothelioma, traditionally, was a disease that affected working males – laborers who worked with asbestos on a day-to-day bases. However, more cases are being diagnosed in a multitude of demographics; men and women of all racial backgrounds are susceptible. In America, homes and buildings constructed prior to 1980 run the risk of housing the deadly material, as it was used extensively in insulation, piping and other home applications. If you suspect your home may contain asbestos, seek out a licensed professional for abatement and removal strategy. OSHA has declared that there is no safe level of asbestos exposure, and awareness of potential hazards to health is paramount.

Follow-up of a Large Prospective United States Cohort by Linkage with Multiple State Cancer Registries

Eric J. Jacobs, PhD, Strategic Director, Pharmacoepidemiology,
American Cancer Society (NAACCR Member)



A validation study was conducted to compare verified self-reports of cancer diagnoses to information in population based cancer registries. Results demonstrate that linkage with the nationwide network of state cancer registries can be a highly sensitive method of identifying diagnoses of most types of cancer among participants in large nationwide research studies.

For the study, registry staff at 23 state cancer registries conducted standardized linkages with a subset of participants in Cancer Prevention Study 3 (CPS-3), a relatively new American Cancer Society (ACS) study including over 300,000 cancer-free U.S. men and women enrolled in 35 states, the District of Columbia and Puerto Rico. ACS researchers plan to follow CPS-3 participants through linkage with state cancer registries for at least 20 years in order to study how a wide range of lifestyle, nutritional, medical, genetic, environmental, and other factors are related to risk of cancer. To determine the sensitivity of multi-state registry linkage, results of registry linkage were compared to new cancer diagnoses that had been reported by a subset of CPS-3 participants and verified by independent collection and review of medical records. Overall, 89% of verified self-reported cancer diagnoses were successfully detected by registry linkage. After excluding melanoma and hematopoietic cancers, which had lower detection rates and may be underreported to registries, the detection rate was an impressive 94%. The authors note that the public has made a substantial investment in state cancer registries, and that making use of these registries to support multi-state linkages for epidemiologic research studies provides an important additional return on this investment.

Based on the positive results from this validation study, American Cancer Society researchers are now beginning to consider the best way to conduct a second round of follow-up linkages for the CPS-3 cohort. This second follow-up round is planned to include linkages with registries from the 23 states included in the validation study (AZ, CA, CO, CT, GA, IL, IN, MA, MD, MI, MN, MO, NC, NJ, NY, OH, OR, PA, SC, TX, VA, WI, and WA) as well as with the cancer registries of the District of Columbia, Puerto Rico, and 12 additional states (AL, AR, FL, IA, KY, LA, MS, NM, OK, SD, TN, UT). We anticipate that using the new NAACCR Virtual Pooled Registry will improve efficiency and yield even higher match rates in the second round.

Click here to view the article
American Journal of Epidemiology


All states in the United States now have a well-established cancer registry. Linkage with these registries may be a cost-effective method of follow-up for cancer incidence in multi-state cohort studies. However, the sensitivity of linkage with the current network of state registries for detecting incident cancer diagnoses within cohort studies is not well-documented. We examined the sensitivity of registry linkage among 39,368 men and women from 23 states who enrolled in the Cancer Prevention Study-3 cohort from 2006-2009 and had the opportunity to self-report cancer diagnoses on a questionnaire in 2011. All participants provided name and birthdate and 94% provided a complete social security number. Of 378 cancer diagnoses between enrollment and 2010 identified through self-report and verified with medical records, 338 were also detected by linkage with the 23 state cancer registries (89% sensitivity, 95% confidence interval (CI): 86%, 92%). Sensitivity was lower for hematologic cancers (69%, 95% CI: 41%, 89%) and melanoma (70%, 95% CI: 57%, 81%). After excluding hematologic cancers and melanoma, sensitivity was 94% (95% CI: 91%, 97%). Our results indicate that linkage with multiple cancer registries can be a sensitive method for ascertaining incident cancers, other than hematologic cancers and melanoma, in multi-state cohort studies.

The opinions expressed in this article are those of the authors and may not represent the official positions of NAACCR.

Cervical cancer screening and incidence near the “stopping” age for screening

Mary C. White, ScD, Chief, Epidemiology and Applied Research Branch, Division of Cancer Prevention and Control
Centers for Disease Control and Prevention (NAACCR Member)

For women between the ages of 21 to 65, Pap testing every three years, or Pap testing with HPV co-testing every five years, can prevent cervical cancer cases and deaths. Current USPSTF recommendations state that women 65 and older (and not otherwise at special risk) can skip Pap tests, but only if they have had three consecutive negative Pap screening tests or two consecutive negative co-tests over the past 10 years, with the most recent done within the past five years. We used combined data from CDC’s NPCR and NCI’s SEER cancer registry programs to examine how cervical cancer risk changes with age, after adjusting population denominators to reflect the estimated proportion of women who have had a hysterectomy by age. We also examined data from CDC’s National Health Interview Survey to determine the proportion of women who either had never been tested or had not been tested in the last 5 years. We concluded that an older woman who has not had her cervix surgically removed has the same or higher risk of developing cervical cancer than a younger woman, consistent with an earlier report using only SEER data. A substantial number of women near the “stopping” age for screening have not been screened for many years. The take-home message is that cervical cancer is not just a young woman’s disease. Women who have not had a hysterectomy remain at risk for cervical cancer as they grow older. It’s important to reach out to women who have not had a hysterectomy and have not been screened for many years, including many older women, to prevent cases of – and deaths from – cervical cancer. Women over 65 who have not been screened for many years still may need to be screened.

Click here to view the article
American Journal of Preventative Medicine


Introduction: Leading professional organizations recommend cervical cancer screening for average-risk women aged 21-65 years. For average-risk women aged >65 years, routine screening may be discontinued if “adequate” screening with negative results is documented. Screening is recommended after age 65 years for women who do not meet adequate prior screening criteria or are at special risk.

Methods: Authors examined the most recent cervical cancer incidence data from two federal cancer surveillance programs for all women by age and race, corrected for hysterectomy status. The 2013 and 2015 National Health Interview Surveys were analyzed in 2016 to examine the proportion of women aged 41-70 years without a hysterectomy who reported that they never had a Pap test or that their most recent Pap test was >5 years ago (not recently screened).

Results: The incidence rate for cervical cancer among older women, corrected for hysterectomy status, did not decline until age ≥85 years. The proportion not recently screened increased with age, from 12.1% for women aged 41-45 years to 18.4% for women aged 61-65 years.

Conclusions: Even among women within the recommended age range for routine screening, many are not up to date, and a substantial number of women approach the “stopping” age for cervical cancer screening without an adequate prior screening history. Efforts are needed to reach women who have not been adequately screened, including women aged >65 years, to prevent invasive cervical cancer cases and deaths among older women.

The opinions expressed in this article are those of the authors and may not represent the official positions of NAACCR.

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