NAACCReview

Xuesong Han, Strategic Director, Health Policy & Healthcare Delivery Research, American Cancer Society

With millions of Americans gaining insurance through the Affordable Care Act, we can expect to see a change in the distribution of insurance status among cancer patients. For example, a recent study published in Cancer (Parsons 2016) identified an increase in the rate of young adult cancer patients with private insurance following the implementation of the ACA dependent care provision in 2010. With the full implementation of the ACA expanding Medicaid eligibility in more than half of the states and creating marketplaces nationwide in 2014, I expect to see an increase in Medicaid and private insurance coverage, along with a decrease in uninsured rate, among cancer patients.

Whether this increase in insurance rate translates to increased access to cancer care and improved cancer outcomes remains to be seen and is important to monitor for cancer control. In the coming years, I would not be surprised if we see an increase in cancer screening uptake and a shift to earlier stage of cancer diagnosis, more cancer patients being able to receive timely treatment, and eventually improved survival and quality of life, especially among those with a low- to medium-income and residing in the states that adopted Medicaid expansion. As a result, we may see a narrowing of the disparities in cancer outcomes by race/ethnicity and socioeconomic status in the coming years.

The Affordable Care Act and Cancer Stage at Diagnosis Among Young Adults (The abstract below is from JNCI Journal of the National Cancer Instititute)

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Recinda L Sherman, MPH, PhD, CTR Program Manager, Data Use & Research North American Association of Central Cancer Registries
(217) 698-0800 x 6; rsherman@naaccr.org

While there are some well established carcinogens, for example tobacco, the largest risk for most cancers is age. And while we understand that individual-level lifestyle factors have a significant impact on cancer incidence, like diet; it is also clear that contextual factors such as poverty and regional policies influence cancer risk and outcomes. We can rightfully highlight public health successes in tobacco cessation and subsequent decline in tobacco-related cancers, as well as other tobacco-affiliated disease. But because cancer has a long latency period and is multicausal, primary prevention efforts are hampered by our limited understanding of what causes most cancers.

This places additional reliance on secondary prevention efforts, primarily screening and effectively treating early stage cancers, to address the burden of cancer. For some cancers, there are effective, population-based screenings, such as for cervical and colorectal cancer. And new advances in low-dose CT scanning are important secondary prevention tools for lung cancer by screening high-risk individuals, based on age and smoking history. Other important secondary prevention efforts include improvements in diagnostic screening tools, intended to screen symptomatic individuals versus the general public, which are also important in influencing stage-shift.

But the focus on detecting early stage cancers is not universally positive and is leading to overdiagonosis, particulary for prostate, breast, melanoma, and thyroid cases. Overdiagnosis is when an asymptomatic cancer is identified through medical technology, but the cancer is either non-invasive or so slow-growing that it would never cause medical problems or be life-threatening. In some cases, an asymptomatic, malignant tumor can regress spontaneously—without medical treatment. The diagnosis of cancer is a frightening event, and, instead of postively impacting mortality, treating overdiagnosed cancers with invasive surgery, radiation, and/or chemotherapy can lead to detrimental side effects. Treatment is uneccessary for overdiagnosed cancers and can lead to physical, psychological, and economic harms.

How do we balance the benefits of cancer screening with the harms of overdiagnosis?

One approach is to remove the label of cancer from the low-risk (overdiagnosed) conditions. For example, thyroid cancer incidence has been on the rise in North American for decades, but mortality rates have remained stable—a discrepancy indicative of high percentages of overdiagnosis. Last week’s article in JAMA Oncology (abstract below) presents a recent revision in nomenclature for an indolent thyroid carcinoma, encapsulated follicular variant of papillary thyroid carcinoma (EFVPTC), to a non-malignant condition. Currently most patients with EFVPTC are treated as having an aggressive thyroid cancer. After conducting an international, retrospective study of EFVPTC patients, a panel of endocrinologists 1) reclassified EFVPTC to a non-malignant condition: non-invasive follicular thyroid neoplasms with papillary-like nuclear features or NIFTP; and 2) developed consensus-based, histopathologic diagnostic criteria to appropriately distinguish NIFTP from malignant thyroid cancer. The study authors have coordinated international support for the proposed declassification from professional societies and are working to publicize both the name and diagnostic criteria among clinicians and pathologists.

What does this mean for cancer surveillance?

We will see a decline in thyroid cancer incidence for cases diagnosed in 2016 forward—how rapid a decline will depend upon how quickly the new diagnostic criteria are adopted by clinicians and how our coding system adapts to reflect the new designation. Below is a rough assessment of the changes we might see. Using histology codes 8335/3 Encapsulated follicular carcinoma, 8343/3 Encapsulated papillary carcinoma, and 8340/3 Papillary carcinoma, follicular variant to approximate NIFTP, we see a 30% decrease in thyroid cancer for diagnosis year 2013 due to the change in classification. And while thyroid incidence is still statistically increasing an average of 5.7% per year, based on this NIFTP estimate, more specific codes for NIFTP may result in a further decline in thyroid cancer incidence trends.

In North America, reportablility follows the guidelines established by the WHO. We will be monitoring WHO “blue books” to see if this reclassification is officially adopted. In order to effectively track the burden of thyroid cancer, the cancer surveillance community will need to ensure our current classification system can accommodate this change, develop guidelines for assessing thyroid cancer trends over time, and educate the public about what is driving the significant drop in thyroid cancer incidence we will see in the new few years.

Nomenclature Revision for Encapsulated Follicular Variant of Papillary Thyroid Carcinoma (The abstract below is from JAMA Oncology)

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A. Blythe Ryerson, MPH, PHD, Interim Chief, Cancer Surveillance Branch, Centers for Disease Control and Prevention (NAACCR Committee Member)
(770) 488-2426; ARyerson@cdc.gov

I’m pleased to announce the release of this year’s Report to the Nation, an annual collaborative effort by CDC, NCI, ACS, and NAACCR. This 18^th “edition” has CDC as the lead agency; however, its success relies upon the tremendous expertise from senior researchers across all the collaborative organizations. Furthermore, no major cancer surveillance report would be possible without the continued dedication and contributions of the state and regional cancer registry staff collecting the data for analysis.

Despite successful reductions in the occurrence and mortality from the most common cancers, some cancers are showing unfavorable trends. Liver cancer, the special focus of the report, has death rates increasing at the highest rate of all cancer sites among men and women, and liver cancer incidence rates are rising at a rate second only to those of thyroid cancer.

A major risk factor for liver cancer is hepatitis C virus (HCV) infection. About 22% of the most common histological type of liver cancer is attributed to HCV. Because rates of chronic HCV infection are most common among people born 1945-1965, CDC recommends one-time testing for HCV for people born during this time. Those who test positive should be referred for appropriate care and treatment. Other strategies for reducing the burden of liver cancer include promoting hepatitis B vaccination, establishing and implementing public health initiatives aimed at reducing unhealthy behaviors such as smoking and excessive alcohol use, and promoting health eating and physical activity to reduce obesity.

Moderate media interest in the topic helped bring attention to the report, including from U.S. News and World Report and multiple national and statewide media outlets. You can read the whole report here. Take a look at the graphics (free for reposting) at www.cdc.gov/cancer.

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Click here to view the report

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

Christopher Johnson, MPH, Epidemiologist, Cancer Data Registry of Idaho (NAACCR Board – Representative-At-Large)

Multiple primary cancers are interesting because they can provide insight into the etiologic role of genes, the environment, and prior cancer treatment on a cancer patient’s risk of developing a subsequent cancer. Over time, the burden of multiple primary cancers has increased as patients are living longer following a diagnosis of cancer.

Cancer registries in the U.S. and the most of Canada use SEER multiple primary rules to count incident cases, while cancer registries in other parts of the world use rules from the International Agency for Research on Cancer and International Association of Cancer Registries (IARC/IACR). Compared to SEER rules, IARC/IACR rules are less complex, have not changed over time, and report fewer multiple primary cancers, particularly cancers that occur in paired organs, at the same anatomic site and with the same or related histologic type. Different rules for registering and reporting multiple primary cancers can make data comparisons between the U.S. and other parts of the world difficult.

SEER*Stat now includes a feature whereby cancer incidence data reported using SEER rules can be analyzed to reflect IARC/IACR rules. In a paper just released by Cancer Causes and Control (see below), we evaluated the effect of SEER and IARC/IACR multiple primary rules on cancer incidence rates and trends using data from the SEER Program. We estimated age-standardized incidence rates and trends (1975–2011) for the top 26 cancer categories using joinpoint regression analysis. Incidence rates were higher using SEER compared to IARC/IACR rules for all cancers combined (3%) and, in rank order, melanoma (9%), female breast (7%), urinary bladder (6%), colon (4%), kidney and renal pelvis (4%), oral cavity and pharynx (3%), lung and bronchus (2%), and non-Hodgkin lymphoma (2%). Differences in incidence rates using the two sets of multiple primary rules were larger for older patients. Trends were similar using both sets of multiple primary rules, with the exception of cancers of the urinary bladder and kidney and renal pelvis.

The choice of multiple primary coding rules affects cancer incidence rates and trends. Entities reporting incidence data using SEER multiple primary rules may want to consider also reporting incidence rates and trends using IARC/IACR rules to facilitate international data comparisons.

Read Full Article (The abstract below is from Springer Link)

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Paulo Pinheiro, MD, MSc, PhD, Associate Professor Epidemiology, University of Nevada Las Vegas (NAACCR Committee Member)

Asian Americans are the fastest-growing racial/ethnic group in the United States. In their newly published manuscript, our colleagues at the University of Nevada Las Vegas estimated detailed incidence rates for 17 cancer sites for the six largest Asian subgroups. They utilized data from SEER and NPCR for 2009-2011 from the 8 states with the largest number of Asians in the US (CA, FL, HI, IL, NJ, NY, TX, and WA). Excellent work has already been published on rates for Asian subgroups by McCracken et al. 2007, Miller et al. 2008, and Gomez et al. 2013, among others. So what’s new about this research? Two main things: one, the coverage of the total US Asian population is 68%, larger than in previous studies, including non-SEER cities with many Asians like Chicago, Houston and New York City; and two, by systematically accounting for Asians with unknown subgroup (Asian-NOS), they produced rates that, for the first time, permit direct comparisons between major Asian subgroups – Chinese, Japanese, South Asian, Korean, Filipino, and Vietnamese- as well as between any given Asian subgroup and other populations such as Whites, Blacks and Hispanics. When NOS cases are excluded, the resulting incidence rates are inevitably underestimated.

Jin et al. imputed Asian subgroup for NOS cases based on age, gender, region of residence, and cancer site. While the assumption of proportional distribution according to these variables may not be perfect, it is certainly a step closer to unbiased final estimates for incidence rates for each Asian subgroup. In their methodology they also took into account that for some Asians groups, e.g. Malay, Indonesian, and others, there are no appropriate race fields available other than NOS.

The analyses showed that Asian Americans have a lower cancer risk than non-Hispanic whites, except for nasopharyngeal, liver and stomach cancers. In comparison to non-Hispanic whites and other Asian subgroups, increased risks were observed for colorectal cancer among Japanese, stomach cancer among Koreans, nasopharyngeal cancer among Chinese, thyroid cancer among Filipinos, and liver cancer among Vietnamese. The unique portrayal of cancer incidence patterns among specific Asian subgroups in this study provides a new baseline for future cancer surveillance research.

Read Full Article (The abstract below is from Wiley Online Library)

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