Cancer Control Report Card: Rhode Island, 1998

John P. Fulton, PhD, is Acting Associate Director, Division of Disease Prevention and Control, Rhode Island Department of Health, and Clinical Associate Professor, Brown University School of Medicine. Dorothy Darcy, AS, CTR, is Director, Cancer Information System, Hospital Association of Rhode Island.

Objective

The Rhode Island Cancer Registry, run collaboratively by the Rhode Island Department of Health (DOH) and the Hospital Association of Rhode Island (HARI), constructed a cancer control report card for Rhode Island, based on available state and national statistics, and referencing Healthy People 2000 cancer control goals.

Methods

Healthy People 2000 cancer control goals and statistics on available indicators of cancer surveillance, prevention, screening, incidence, and mortality were abstracted or calculated from four national publications^1,2,3,4 and the Rhode Island Behavioral Risk Factor Surveillance System.

Current Rhode Island statistics on target activities, indicators, and rates were compared with past Rhode Island statistics, current United States statistics, and Healthy People 2000 cancer control goals to evaluate the State's progress toward reducing the burden of cancer among all Rhode Islanders. Progress towards Healthy People 2000 goals was evaluated.

Cancer Control Report Card, Part 1: Prevention and Screening Activities
Target Activity	Yr 2000 Goal	Base Yr RI	Late Yr All States	Base % RI	Late % RI	Late % Median State	Progress RI
• Decrease % adults smoking cigarettes.	15%	1990	1995	25.7	24.7	22.4	+
• Increase % adults getting regular leisure time physical activity.	30%	1990	1994	44.0	45.8	34.3	+
• Increase % adults eating five fruits and vegetables daily.	100%	1993	1996	25.5	24.1	NA*	–
• Decrease % adults overweight.	20%	1990	1995	23.9m 20.9f	28.6m 21.6f	30.6m 26.4f	– –
• Increase % women ages 18-44 getting biennual Pap test. • Increase % women ages 45+ getting biennual Pap test.	85† 85†	1991 1991	1995 1995	84.5 63.2	83.0 68.1	83.1 72.7	– +
• Increase % women ages 40-49 getting biennial mammogram. • Increase % women ages 50+ getting annual mammogram.	NA* 60%	1990 1990	1995 1995	66.5 60.9	74.6 49.7	65.5 54.9	+ –
• Increase % adults ages 40+ getting annual rectal exam.	50‡	1993	1995	49.5	52.8	40.7	+

* NA = Not Available.
† Yr 2000 goal: Pap test every 1-3 years.
‡ Yr 2000 goal: fecal occult blood test every 1-2 years, adults ages 50 and over.

Cancer Control Report Card, Part 2: Surveillance; Cancer Registry Quality Control Indicators
Target Indicator	% Goal*	Period	% RI	Progress RI
Reduce the % of duplicate reports.	0.1	90-94	0.1	++
Increase the % of completeness of case reporting.	90	90-94	97	++
Limit the % of cases with information from death certificate only.	3	90-94	1.6	++

* Established by the North American Association of Central Cancer Registries

Cancer Control Report Card, Part 3: Incidence and Mortality Rates
Target Cancer Rate (Cases or Deaths per 100000, Age-Adjusted to the 1970 US Pop)	Yr 2000 Goal	Base Yr RI	Late Yr All States	Base Rt RI	Late Rt RI	Late Rt Median State	Progress RI
Decrease incidence of lung cancer.	NA*	88-90	90-94	90.3 m 40.6 f	89.9 m 45.2 f	79.5 m 42.0 f	+ –
Decrease incidence of cervical cancer.	NA	88-90	90-94	7.4 f	9.3 f	9.4 f	–
Decrease incidence of colo-rectal cancer.	NA	88-90	90-94	74.2 m 46.0 f	67.1 m 45.5 f	55.8 m 38.9 f	+ +/–
Decrease incidence of all cancers combined.	NA	88-90	90-94	441.0m 344.9f	493.5m 361.4f	485.1m 342.4f	– –
Decrease mortality from lung cancer.	53.0†	88-92	90-94	75.7 m 31.4 f	75.4 m 32.8 f	73.2 m 32.8 f	+ –
Decrease mortality from cervical cancer.	1.5	88-92	90-94	2.4 f	2.6 f	2.9 f	+/–
Decrease mortality from colorectal cancer.	18.7†	88-92	90-94	28.2 m 17.6 f	25.9 m 16.3 f	22.4 m 15.1 f	+ +
Decrease mortality from breast cancer.	25.2	88-92	90-94	31.6 f	29.3 f	26.4 f	+
Decrease mortality from all cancers combined.	175.0†	88-92	90-94	234.0m 147.9f	226.8m 147.2f	217.9m 141.7f	+ +/–

* NA = Not Available. Yr 2000 cancer incidence goals were not defined.
† Yr 2000 cancer control mortality goals were not defined by sex.

Highlights:

Prevention

Fewer adults smoke cigarettes.
More adults exercise regularly.

Screening

More women ages 45+ get biennial Pap tests.
More women ages 40-49 get biennial mammograms.
More adults get annual rectal exams. Rhode Island exceeds the Healthy People 2000 goal for this screening activity.

Surveillance

The Rhode Island Cancer Registry meets all standards for the inclusion of Rhode Island data in the calculation of incidence rates for the United States as a whole and for North America as a whole, as published annually in Cancer in North America.

Incidence Rates

Male lung cancer rates have plateaued.
Male colo-rectal cancer rates have decreased.

Mortality Rates

Male lung cancer rates have plateaued.
Colo-rectal cancer rates have decreased.
Breast cancer rates have decreased.
Male "all cancer" rates have decreased.

Concerns:

Prevention

Fewer adults eat at least 5 servings of fruits and vegetables per day.
More adults, especially men, are overweight, although Rhode Island is very close to the Healthy People 2000 goal for decreasing the prevalence of overweight among women.

Screening

Fewer women ages 18-44 get biennial Pap tests, but Rhode Island is close to achieving the Healthy People 2000 goal for cervical cancer screening in this age group.
Fewer women ages 50+ get annual mammograms. In 1990, Rhode Island exceeded the Healthy People 2000 goal for screening mammography among women ages 50+.

Incidence Rates

Female lung cancer rates have increased.
Cervical cancer rates have increased.
"All cancer" rates have increased.

Mortality Rates

Female lung cancer rates have increased.

Discussion

Overall, Rhode Island is moving ahead toward the achievement of Healthy People 2000 cancer control goals. Smoking is down, exercise is up, cancer screening is generally up or strong, and we have begun to see decreases in cancer incidence and mortality.

That adult smoking is decreasing is especially heartening, as tobacco use causes almost half the cancers in the United States. In Utah, where the latest adult smoking prevalence is 13.2%, cancer incidence and mortality from all cancers combined is the lowest in the nation. Even though lung cancer incidence and mortality is on the increase among Rhode Island women, these trends will reverse, because of the downward trend in adult smoking (in women as well as men). Lung cancer rates among women should peak considerably lower than the lung cancer rates for men, because women never achieved the same smoking prevalence as men, despite the best efforts of the tobacco industry to develop the market among women.

Cancer surveillance in Rhode Island has been strengthened substantially by funding from the Centers for Disease Control and Prevention’s National Program of Cancer Registries, which allows cancer registrars from the Hospital Association of Rhode Island to assist cancer registrars in the community with quality assurance functions aimed at increasing the completeness and accuracy of cancer case reporting.

That mortality from breast and colorectal cancer is down is consistent with the gains made in screening for these two diseases. The use of the annual rectal examination in Rhode Island is especially noteworthy, as it exceeded the Healthy People 2000 goal in 1995. Despite setbacks in the use of mammography attributable to Medicare’s retrenchment in reimbursement for the procedure among women ages 65 and over, Rhode Island’s breast cancer screening profile remains strong. The frequency of mammography use among women ages 40-49 is close to the highest in the nation. With support from their peers, families, and health care providers, women ages 40-49 should maintain this positive health behavior as they grow older. Mammography use should also increase substantially among women ages 50 and over, following Medicare’s recent decision to reimburse annual mammography for women ages 65 and over, once again. Hopefully, Rhode Island’s use of mammography among women ages 50 and over will quickly increase to its 1990 level (meeting the Healthy People 2000 goal) and beyond.

Nontheless, certain concerns remain. The Rhode Island diet is not rich in fruits and vegetables, and the trend seems to be in the wrong direction. Perhaps related to this, the proportion of adults who are overweight has increased over time. Diet is difficult to change, and interventions to effect changes in diet can be costly. Nonethelesss, we must persist in this effort. Balancing the Rhode Island diet would not only help prevent colorectal cancer, but would have salutary effects on cardiovascular disease, diabetes, and the disabling effects of overweight, especially among elders.

The incidence of cervical cancer has increased. Despite Rhode Island’s strong showing with regard to use of the Pap test, we must screen more intensively. Theoretically, we can achieve zero incidence of cervical cancer through effective screening. Almost all cervical lesions develop slowly enough that biennial Pap smears should identify them as pre-cancerous infections or dysplasias.

References

1. U.S. Public Health Service. Healthy People 2000. Washington, D.C.: U.S. DHHS, 1991.

2. American Cancer Society. Cancer Risk Report. Prevention and Control 1997. Atlanta, GA: American Cancer Society, 1997.

3. Chen VW, Wu XC, Andrews PA (eds). Cancer in North America, 1990-1994. Volumes One and Two: Incidence and Mortality. Sacramento, CA: North American Association of Central Cancer Registries, 1998.

4. Kosary CL, Ries LAG, Miller BA, Hankey BF, Harras A, Edwards BK (eds). SEER Cancer Statistics Review, 1973-1992: Tabes and Graphs. National Cancer Institute. NIH Pub. No. 96-2789. Bethesda, MD, 1995.

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