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The number of dedicated mammography machines installed in the United States has grown explosively. It is estimated that almost 10,000 machines will be installed by 1990, whereas the projected demand for screening mammography will require only approximately 2,600 machines, if the machines are used in a moderately efficient manner. The excess supply of mammography resources raises concern from an economic perspective for several reasons. First, such a condition means that health care resources are being used inefficiently. Second, the low average utilization rate of mammography equipment implied by these results necessitates charging a high price-over $100, on average-to cover costs. This price is above the $50 usually associated with low-cost screening mammography programs, and it may impede a desirable public health trend to increase use of mammography screening. Third, the existence of many mammography facilities operating at low capacity levels is inefficient from a health systems perspective, increasing the cost of quality assurance and medical record keeping. The current condition of excess supply is probably unsustainable over the long term. [ABSTRACT FROM AUTHOR]

The Dietary Guidelines for Americans 2005 report recommends 3 or more daily ounce-equivalents of whole grains (WG), and the FDA suggests consumption of 25 g of total dietary fiber (TDF) and 6 g of soluble fiber (SF) for a 2000-calorie diet. Efforts to increase the consumption of WG and SF among elementary school-aged children are needed. The objectives of this study were to examine the consumption of WG- and SF-enriched burritos and cookies among elementary school-aged children and to perform a quality evaluation of all products. Children in grades K to 6 from a local elementary school consumed control (CTR) products made with refined flour along with the test products (TRT) over a 13-wk period. TRT burritos and cookies contained 51% and 100% WG, respectively. CTR and TRT products were served on 3 and 4 different Fridays, respectively. Children's consumption was determined via plate waste. Quality parameters such as texture, color, water activity, weight, and product dimensions were also measured. No significant differences in consumption between CTR and TRT burritos and cookies were found (36% and 90%, respectively). Texture (area) was higher for CTR burritos compared with TRT burritos (1.31 and 0.66 kg-s, respectively). CTR burritos were lighter than TRT burritos with L* values of 80.04 and 64.61, respectively. CTR cookies required a higher breaking force (3.14 compared with 0.58 kg), were lighter than TRT cookies (63.18 compared with 50.27), and had lower water activity (0.5 compared with 0.71). [ABSTRACT FROM AUTHOR]

Previous studies indicate that hospital rather than home treatment of pulmonary exacerbations (PEx) in people with cystic fibrosis (CF) can improve outcomes. We evaluated characteristics of adult participants from the Standardized Treatment of Pulmonary Exacerbations (STOP2) trial with two separate comparisons: (1) those who were treated initially in hospital (N = 768) to those treated initially at home (N = 214) and (2) those treated only in hospital (N = 328) to those who were treated only at home or both at home and in hospital (N = 654). Participants who had Medicaid insurance, were treated for shorter duration, and traveled longer to reach treatment centers were more likely to have been treated initially in the hospital. Having Medicaid insurance, being treated for a shorter duration, and being male were associated with being treated only in the hospital. This analysis suggests decisions about the location of treatment are based on pragmatic factors rather than on clinical characteristics., Competing Interests: Declaration of Competing Interest Grants from the Cystic Fibrosis Foundation in part supported the salaries of LSG, RNH, SLH, PAF, CHG, NEW, DBS, and LK. Grants from the NIH in part supported the salaries of SLH, PAF, and CHG. DBS received payments for committee work from the Cystic Fibrosis foundation. DBS's institution also grant support payments from Gilead Sciences and the CHEST Foundation. DBS received personal payment for participation on an advisory board for Vertex Pharmaceuticals., (Copyright © 2023. Published by Elsevier B.V.)

With increased attention to the financing and structure of healthcare, dramatic increases in the cost of diagnosing and treating cancer, and corresponding disparities in access, the study of healthcare economics and delivery has become increasingly important. The Healthcare Delivery Research Program (HDRP) in the Division of Cancer Control and Population Sciences at the National Cancer Institute (NCI) was formed in 2015 to provide a hub for cancer-related healthcare delivery and economics research. However, the roots of this program trace back much farther, at least to the formation of the NCI Division of Cancer Prevention and Control in 1983. The creation of a division focused on understanding and explaining trends in cancer morbidity and mortality was instrumental in setting the direction of cancer-related healthcare delivery and health economics research over the subsequent decades. In this commentary, we provide a brief history of health economics and healthcare delivery research at NCI, describing the organizational structure and highlighting key initiatives developed by the division, and also briefly discuss future directions. HDRP and its predecessors have supported the growth and evolution of these fields through the funding of grants and contracts; the development of data, tools, and other research resources; and thought leadership including stimulation of research on previously understudied topics. As the availability of new data, methods, and computing capacity to evaluate cancer-related healthcare delivery and economics expand, HDRP aims to continue to support this growth and evolution., (Published by Oxford University Press 2022. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Background: Pulmonary exacerbations (PEx) in cystic fibrosis (CF) patients decrease lung function, increase symptoms and reduce health-related quality of life (HRQoL). We evaluated associations between 8 symptom-based questions from the Cystic Fibrosis Respiratory Symptom Diary - Chronic Respiratory Infection Symptom Score (CFRSD-CRISS) and the 5-level EuroQOL-5 Dimensions (EQ-5D-5 L) summary score and hypothesized the CFRSD-CRISS would be well-correlated with quality-of-life measures among CF patients with PEx., Methods: CF patients who had CFRSD-CRISS and EQ-5D-5L measurements on the day of the initial PEx, 7 days later, and at the end of intravenous antibiotic treatment were included. We examined age-stratified (<18 versus ≥18 years old) characteristics, including the percent predicted of forced expiratory volume in 1 s (ppFEV1), CFRSD-CRISS measurements, and domains of the EQ-5D. We also calculated age-stratified Pearson correlation coefficients between the EQ-5D-5L and CFRSD-CRISS items at each of the 3 time points., Results: A total of 169 patients were analyzed. Patients reported having problems performing usual activities and with pain/discomfort on the first day of the PEx and these measures improved by the end of treatment. PpFEV1 improved in both age categories by the end of PEx treatment but was not associated with the change in summary EQ-5D-5 L over the time of PEx treatment (r-squared = 0.029). Correlations were weak (generally <0.4) between the elements of the EQ-5D-5 L versus the CFRSD-CRISS., Conclusions: Value assessment of treatments for CF PEx will require the collection of preference-weighted measures rather than only the symptom-based questions of the CFRSD-CRISS., (Copyright © 2018 European Cystic Fibrosis Society. Published by Elsevier B.V. All rights reserved.)

Background and Aims: Prior studies suggest that colonoscopy may exacerbate inflammatory bowel disease (IBD) symptoms. Thus, our study aimed to determine risk of emergency room (ER) visits associated with colonoscopy among IBD patients and evaluate potential modifiers of this risk., Methods: The study population included IBD patients in the Multi-Payer Claims Database who were >20 years old and had a colonoscopy from 2007-2010. We used a self-controlled risk interval design and mixed-effects Poisson regression models to calculate risk ratios (RR) and 95% confidence intervals (CI) comparing the incidence of ER visits in the 1-4 weeks following colonoscopy (risk interval) to the incidence of ER visits in the 7-10 weeks after colonoscopy (control interval). We also conducted stratified analyses by patient characteristics, bowel preparation type, and medication., Results: There were 212,205 IBD patients with at least 1 colonoscopy from 2007-2010, and 3,699 had an ER visit during the risk and/or control interval. The risk of an ER visit was higher in the 4-week risk interval following colonoscopy compared to the control interval (RR = 1.24; 95% CI: 1.17-1.32). The effect was strongest in those <41 years old (RR = 1.60; 95% CI: 1.21-2.11), in women (RR = 1.32; 95% CI: 1.21-1.44), and in those with sodium phosphate bowel preparation (RR = 2.09; 95% CI: 1.02-4.29). Patients using immunomodulators had no increased risk of ER visits (RR = 0.75; 95% CI: 0.35-1.59)., Conclusions: Our results suggest that there is an increased risk of ER visits following colonoscopy among IBD patients, but that immunomodulators and mild bowel preparation agents may mitigate this risk., Competing Interests: The authors have declared that no competing interests exist.

Introduction: Because receipt of breast imaging likely occurs in nonrandom patterns, selection bias is an important issue in studies that attempt to elucidate associations between imaging and breast cancer outcomes. The purpose of this study was to analyze use of advanced diagnostic imaging in a cohort of patients with breast cancer insured by commercial, managed care, and public health plans by demographic, health insurance, and clinical variables from 2002 to 2009., Methods: We identified women with breast cancer diagnoses from a Surveillance Epidemiology and End Results (SEER) registry whose data could be linked to claims from participating health plans. We examined imaging that occurred between cancer diagnosis and initiation of treatment and classified patients according to receipt of (1) mammography or ultrasound only; (2) breast magnetic resonance imaging (MRI); and (3) other advanced imaging (computed tomography [CT] of the chest, abdoment, and pelvis; positron emission tomography [PET]; or PET-CT). We used logistic regression to identify factors associated with receipt of breast MRI as well as other advanced imaging., Results: Commercial health plan, younger age, and later year of diagnosis were strongly associated with receipt of breast MRI and other advanced imaging. Women with prescription drug plans and those who had less comorbidities were more likely to have received breast MRI., Conclusion: Use of breast MRI and other advanced imaging is increasing among patients newly diagnosed with breast cancer; individual patient and insurance-related factors are associated with receipt of these imaging tests. Whether use of diagnostic advanced imaging affects outcomes such as re-excision, cancer recurrence, mortality rates, and costs of breast cancer treatment remains to be determined.

In this article, we trace the chronology of developments in breast imaging technologies that are used for diagnosis and staging of breast cancer, including mammography, ultrasonography, magnetic resonance imaging, computed tomography, and positron emission tomography. We explore factors that affected clinical acceptance and utilization of these technologies from discovery to clinical use, including milestones in peer-reviewed publication, US Food and Drug Administration approval, reimbursement by payers, and adoption into clinical guidelines. The factors driving utilization of new imaging technologies are mainly driven by regulatory approval and reimbursement by payers rather than evidence that they provide benefits to patients. Comparative effectiveness research can serve as a useful tool to investigate whether these imaging modalities provide information that improves patient outcomes in real-world settings.

In June 2009, the Federal Coordinating Council for Comparative Effectiveness Research submitted a report to the President and Congress in which the Council described the purpose of comparative effectiveness research (CER) as developing evidence-based information for interventions and determining under what circumstances an intervention is effective (1). With the enactment of the Patient Protection and Affordable Care Act, a Patient-centered Outcomes Research Institute (PCORI) was established to assist decision makers in making evidence-based health decisions through synthesis and dissemination of clinical CER of health interventions (2). Its founding has underscored a heightened need for health policy makers to consider the impact of health care technologies on final outcomes of interest--for example, functional status, quality of life, disability, major clinical events, and mortality (3-5)., (© RSNA, 2011.)

The pace of medical technological development shows no sign of abating. Analyzing the effect of major federal health agencies on the availability of such technology is critical. This paper describes functions of three government health agencies: the Centers for Medicare and Medicaid Services (CMS), the Food and Drug Administration (FDA), and the National Institutes of Health (NIH). Certain medical technologies fall into gaps between these agencies, which pose challenges in today's era of demand for evidence-based medicine. We suggest new policy and pragmatic strategies that can close the gaps and move decision making relevant to technology forward more rapidly than is now the case.

Rationale and Objectives: Bringing a new imaging technology to market is a complex process. Beyond conceptualization and proof of concept, obtaining U.S. Food and Drug Administration (FDA) approval for clinical use depends on the documented experimental establishment of safety and efficacy. In turn, safety and efficacy are evaluated in the context of the intended use of the technology. The purpose of this study was to examine a conceptual framework for technology development and evaluation, focusing on new breast imaging technologies as a highly visible and current case in point., Materials and Methods: The FDA views technology development in terms of a preclinical and four clinical phases of assessment. With a concept of research and development as a learning model, this phased-assessment concept of regulatory review against intended use was integrated with a five-level version of a hierarchy-of-efficacy framework for evaluating imaging technologies. Study design and analysis issues are presented in this context, as are approaches to supporting expanded clinical indications and new intended uses after a new technology is marketed., Conclusion: Breast imaging technologies may be intended for use as replacements for standard-of-care technologies, as adjuncts, or as complementary technologies. Study designs must be appropriate to establish claims of superiority or equivalence to the standard for the intended use. Screening technologies are ultimately judged on their demonstrated effectiveness in decreasing cause-specific mortality through early detection, but they may be brought to market for other uses on the basis of lesser standards of efficacy (eg, sensitivity, specificity, positive and negative predictive value, and stage of disease detected).

Case reports were received of a fatal tachycardia caused by a malfunction of an implantable cardioverter defibrillator (ICD), a device that is subject to the tracking regulations of the Food and Drug Administration's Center for Devices and Radiological Health. The case reports led to a decision to notify 5,604 patients of the need for reprogramming of their ICDs to prevent the tachycordia. In the first 60 days, a total of 98.7% of the patients were successfully located and their devices reprogrammed. Multiple logistic regression analysis was conducted to examine an extensive array of factors that might have been related to the time to reprogramming. Patient-specific factors such as age, sex, and ejection fraction did not serve as a barrier to reprogramming in the first week (p = NS). Patients whose regular physician had >5 patients with the ICD subject to the recall were significantly more likely to have their ICDs reprogrammed in the first week (odds ratio [OR] 2.11, 95% confidence interval [CI] 1.85 to 2.43, p<0.001). Patients who changed physicians were significantly less likely to undergo reprogramming in the first week (OR 0.73, 95% CI 0.63 to 0.86, p<0.001). The experience of the recall of this tracked device is highly encouraging because it demonstrates that most tracked device recipients can be successfully located and receive medical intervention. Although tracking devices is a manufacturer's responsibility, the clinical community plays a critical role in its success. This report highlights the importance of understanding that role among physicians.

Background: Lifetime risk estimates of disease are limited by long-term data extrapolations and are less relevant to individuals who have already lived a period of time without the disease, but are approaching the age at which the disease risk becomes common. In contrast, short-term age-conditional risk estimates, such as the risk of developing a disease in the next 10 years among those alive and free of the disease at a given age, are less restricted by long-term extrapolation of current rates and can present patients with risk information tailored to their age. This study focuses on short-term age-conditional risk estimates for a broad set of important chronic diseases and nondisease causes of death among white and black men and women., Methods: The Feuer et al. (1993, Journal of the National Cancer Institute) [15] method was applied to data from a variety of sources to obtain risk estimates for select cancers, myocardial infarction, diabetes mellitus, multiple sclerosis, Alzheimer's, and death from motor vehicle accidents, homicide or legal intervention, and suicide., Results: Acute deaths from suicide, homicide or legal intervention, and fatal motor vehicle accidents dominate the risk picture for persons in their 20s, with only diabetes mellitus and end-stage renal disease therapy (for blacks only) having similar levels of risk in this age range. Late in life, cancer, acute myocardial infarction, Alzheimer's, and stroke become most common. The chronic diseases affecting the population later in life present the most likely diseases someone will face. Several interesting differences in disease and death risks were derived and reported among age-specific race and gender subgroups of the population., Conclusion: Presentation of risk estimates for a broad set of chronic diseases and nondisease causes of death within short-term age ranges among population subgroups provides tailored information that may lead to better educated prevention, screening, and control behaviors and more efficient allocation of health resources.

We reviewed the Food and Drug Administration's regulatory process for medical devices and described the issues that arise in assessing device safety and effectiveness during the postmarket period. The Center for Devices and Radiological Health (CDRH), an organization within the Food and Drug Administration, has the legal authority and responsibility for ensuring that medical devices marketed in the United States are both reasonably safe and effective for their intended use. This is an enormous challenge given the diversity of medical devices and the large number of different types of devices on the market. Many scientific and regulatory activities are necessary to ensure device safety and effectiveness, including technology assessment, albeit in a manner quite different from that of conventional technology assessment. The basic approach taken at the CDRH to ensure device safety and effectiveness is to develop an understanding of the way in which a medical device works and how it will perform in clinical situations.

Background: There are more than 500,000 deaths from cancer each year in the United States. This study examines Americans' knowledge of risk factors for breast, cervical, colon, and prostate cancers, which account for over 130,000 of these deaths, and their knowledge of the prospects of surviving these cancers following early detection., Methods: Data were obtained from 12,035 subjects who completed the 1992 National Health Interview Survey Cancer Control Supplement which includes questions about cancer risk factors and survival., Results: The majority of respondents were unable to identify major cancer risk factors when prompted with a list. Approximately two-thirds did not recognize that age increased the risk for breast and colon cancer, that diet increased the risk for colon cancer, or that multiple sex partners increased the risk for cervical cancer. Knowledge about survival was also poor. Only about half thought they had a good chance of survival following early detection of colon and cervical cancers, for which 5-year relative survival exceeds 90%., Conclusions: Americans lack knowledge about major risk factors for common cancers and about the prospects of survival following early detection. Knowledge about risk factors and about survival from cervical and colon cancers was poor at all ages, among all races, at all income levels, and at all educational levels. It was poorest among blacks and Hispanics and among those with the lowest income and least education. Americans need education about cancer risk factors and survival.

Background: Cigarette smoking is responsible for at least one third of all cancer deaths annually in the United States. Few sources exist in the peer-reviewed literature documenting state and regional differences in smoking behavior, despite the fact that cancer prevention and control efforts are increasingly being implemented below the national level., Purpose: Our goals were to determine smoking prevalence rates among men and women, by region, and for each of the 50 states and the District of Columbia from census survey data collected in 1992 and 1993 and to compare these rates with rates determined in 1985., Methods: Every month, the U.S. Bureau of the Census collects labor force statistics on more than 100000 individuals on its Current Population Survey (CPS). For the September 1992, January 1993, and May 1993 CPS, the National Cancer Institute sponsored a 40-item Tobacco Use Supplement. The definition of a current smoker changed slightly between 1985 and 1992-1993. For the 1985 CPS, individuals were considered current smokers if they had smoked 100 cigarettes in their lifetime and were smoking at the time of interview; for the 1992-1993 CPS, current smokers included anyone who had smoked 100 cigarettes and was currently smoking every day or just on some days. We calculated current smoking rates (every day and some days combined) based on more than a quarter million adults (n = 266988) interviewed in 1992-1993., Results: Substantial geographic variation exists in rates of current cigarette use among adults within the United States. In general, adults in the southern United States have higher rates of smoking and adults in the western states have lower rates of smoking and adults in the rest of the country, although differences in smoking behavior between men and women and among various racial and ethnic populations strongly influence these patterns. Only two states, Kentucky and West Virginia, exhibited adult smoking rates (men and women combined) of 30% or higher in 1992-1993; in contrast, in 1985, such rates were reported from 20 states. The only states in which the prevalence was below 20% in 1992-1993 were Utah (17.1%) and California (19.5%). Rates approaching 20% were reported from New Jersey (20.7%), Massachusetts (21.5%), and Nebraska, New York, and Hawaii (22.0% each) in 1992-1993. Rhode Island experienced the greatest relative decline in smoking prevalence from 1985 to 1992-1993, with a calculated relative change of -30.7% (based on a change in rate from 33.5% to 23.2%), followed by Delaware (-25.9%) the District of Columbia and New Jersey (-23.9% each), Connecticut (-23.2%), California (-22.9%), Alaska (-22.8%), Georgia (-22.6%), Massachusetts (-22.1%), and New York (-22.0%)., Conclusions: Smoking rates are not uniform in the United States but vary considerably from state to state, even within the same region of the country. The CPS is the only mechanism currently capable of simultaneously monitoring smoking trends nationally, regionally, and on a state-by-state basis.

Background: Clinical trials have demonstrated that use of mammographic screening and advances in therapy can improve prognosis for women with breast cancer., Purpose: We determined the trends in breast cancer mortality rates, as well as incidence and survival rates by extent of disease at diagnosis, for white women in the United States and considered whether these trends are consistent with widespread use of such beneficial medical interventions., Methods: We examined mortality data from the National Center for Health Statistics and incidence and survival data by extent of disease from the Surveillance, Epidemiology, and End Results Program of the National Cancer Institute, all stratified by patient age, using statistical-regression techniques to determine changes in the slope of trends over time., Results: The age-adjusted breast cancer mortality rate for U.S. white females dropped 6.8% from 1989 through 1993. A significant decrease in the slope of the mortality trend of approximately 2% per year was observed in every decade of age from 40 to 79 years of age. Trends in incidence rates were also similar among these age groups: localized disease rates increased rapidly from 1982 through 1987 and stabilized or increased more slowly thereafter; regional disease rates decreased after 1987; and distant disease rates have remained level over the past 20 years. Three-year relative survival rates increased steadily and significantly for both localized and regional disease from 1980 through 1989 in all ages, with no evidence of an increase in slope in the late 1980s., Implications: The decrease in the diagnosis of regional disease in the late 1980s in women over the age of 40 years likely reflects the increased use of mammography earlier in the 1980s. The increase in survival rates, particularly for regional disease, likely reflects improvements in systemic adjuvant therapy. Statistical modeling indicates that the recent drop in breast cancer mortality is too rapid to be explained only by the increased use of mammography; likewise, there has been no equivalent dramatic increase in survival rates that would implicate therapy alone. Thus, indications are that both are involved in the recent rapid decline in breast cancer mortality rates in the United States.

This overview of medical device vigilance at the U.S. Food and Drug Administration (FDA) discusses the basic reporting regulation and program at FDA. The FDA program has grown to the point where we now receive over 100,000 reports per year. How FDA examines the data patterns in overall reporting, to identify signals in the database, and the potential actions FDA takes to respond to these problems are also presented. New initiatives include, for example, new methods to triage reports and the move developing an internationally harmonised nomenclature.

Until now, the only cancers that have been strongly associated with AIDS are Kaposi's sarcoma and non-Hodgkin lymphoma. We used a linkage between AIDS (50,050 reports) and cancer (859,398 reports) registries in seven health departments in the USA to investigate the association between HIV infection and epidermoid anal cancer. We compared the numbers of observed cases and expected cases, calculated from general population rates with adjustment for age, sex, and race. The relative risk of anal cancer at and after AIDS diagnosis was 84.1 (95% CI 46.4-152) among homosexual patients (11 cases) and 37.7 (9.4-151) among non-homosexual patients (2 cases). The relative risk of anal cancer up to 5 years before the AIDS diagnosis (23 cases) was also increased; it was 13.9 (6.6-29.2) in the period 2-5 years before AIDS and 27.4 (15.9-47.2) during the 2 years before AIDS diagnosis (p for trend = 0.004). Among homosexual men, the relative risk of anal cancer was inversely related to age at AIDS onset (p for trend < 0.001). Excess risks were found in all geographical areas. This study establishes a strikingly increased risk of anal cancer among people with AIDS. These data are consistent with a previously hypothesized association between HIV-induced immunodeficiency and anal cancer development, but because homosexual men were at increased risk of anal cancer even before the AIDS epidemic, we cannot say how much of the increased risk is attributable to HIV infection. Nevertheless, clinicians should be aware that AIDS patients have an increased risk of anal cancer.

Objectives: Mammography rates reported by women in the National Health Interview Surveys of 1990 and 1987 are examined. Why this screening modality is not more frequently used is explored., Methods: Data from the 1987 and 1990 National Health Interview Surveys, conducted by the National Center for Health Statistics, are cross-tabulated and compared., Results: In 1987, approximately 17% of women over 40 years of age reported having had a screening mammogram in the previous year. In 1990, the rate doubled. Race declined in importance; income and education remained strong, positive predictors of screening., Conclusions: Despite this dramatic increase, two thirds of women are not having screening mammograms. Use was not higher primarily because women did not realize that screening mammography tests for breast cancer in asymptomatic women. Primary care physicians are the main source of health education for screening mammography. The data suggest that public health programs to promote screening mammography should especially target primary care physicians and women with low incomes and education. Likewise, health care providers should ensure that their patients are referred to facilities that deliver high-quality mammography at low cost to make the procedure more accessible.

The National Cancer Institute and the Health Care Financing Administration share a strong research interest in cancer costs, access to cancer prevention and treatment services, and cancer patient outcomes. To develop a database for such research, the two agencies have undertaken a collaborative effort to link Medicare Program data with the Surveillance, Epidemiology, and End Results (SEER) Program database. The SEER Program is a system of 9 population-based tumor registries that collect standardized clinical information on cases diagnosed in separate, geographically defined areas covering approximately 10% of the US population. Using a deterministic matching algorithm, the records of 94% of SEER registry cases diagnosed at age 65 or older between 1973 to 1989, or more than 610,000 persons, were successfully linked with Medicare claims files. The resulting database, combining clinical characteristics with information on utilization and costs, will permit the investigation of the contribution of various patient and health care setting factors to treatment patterns, costs, and medical outcomes.

This paper describes the development of a model for making project funding decisions at The National Cancer Institute (NCI). The American Stop Smoking Intervention Study (ASSIST) is a multiple-year, multiple-site demonstration project, aimed at reducing smoking prevalence. The initial request for ASSIST proposals was answered by about twice as many states as could be funded. Scientific peer review of the proposals was the primary criterion used for funding decisions. However, a modified Delphi process made explicit several criteria of secondary importance. A structured questionnaire identified the relative importance of these secondary criteria, some of which we incorporated into a composite preference function. We modeled the proposal funding decision as a zero-one program, and adjusted the preference function and available budget parametrically to generate many suitable outcomes. The actual funding decision, identified by our model, offers significant advantages over manually generated solutions found by experts at NCI.

An assessment of the prevalence and scope of nutrition services offered through 208 randomly selected American College Health Association member student health centers revealed that 79% of the 160 respondents provided some type of nutrition education for students. One-to-one counseling, available at 96% of the institutions, was the most common approach. The larger the school's enrollment, the more likely it was to provide programs in nutrition. All of the institutions with student populations of more than 35,000 offered some type of nutrition service, as did 52% of the 19 schools with enrollments between 2,000 and 5,000. Health educators, nurses, doctors, dietitians, and trained peer educators provided the services, with registered dietitians the most common providers and often coordinators of the programs. Costs to students for nutrition interventions were nominal; weight-management programs were the most expensive and showed the greatest variation in content.

Background: Mortality, incidence, and survival rates are the primary measures used by the National Cancer Institute (NCI) to monitor cancer in the United States. The Surveillance, Epidemiology, and End Results (SEER) data system collects data on all cancers diagnosed among residents in geographically defined populations, which comprise about 10% of the U.S. population. This data system is the major component of the NCI system for tracking these rates. Thus, it is important to assess the degree to which SEER data are representative of the entire U.S. population., Purpose: National data on mortality, but not on incidence or survival, are available from the National Center for Health Statistics. These data provide a census against which mortality data from the subset of the SEER regions may be compared., Methods: Multivariate regression analyses of age-adjusted mortality rates from 1975 to 1988, computed for the SEER areas and for the entire United States, were performed for race- and sex-specific data from 15 cancer sites. Representativeness was evaluated by testing for differences in trends and levels between the data from the U.S. population and those from the SEER Program., Results: Data from the SEER regions reflected the correct direction of trend for all sites, although some race-, sex-, and site-specific differences existed for the magnitude of the trends and levels of mortality when compared with data from the U.S. population., Conclusions: The demonstration that data from the SEER population do occasionally yield mortality rates that differ from those for the entire U.S. population suggests that data from the SEER coverage population are, in some cases, not representative of the greater U.S. population., Implications: This issue is of particular relevance to the interpretation of incidence measures, computed from the SEER data, for which there is no national database. Future efforts should be directed at a better understanding of how the SEER population differs from the U.S. population so that SEER rates can be adjusted to be more nationally representative.

No national data exist on the prevalence of cancer in the United States population. The authors report the first estimates of prevalence rates of cancer from a population-based sample of the adult population of the United States. Estimates are based on responses collected from the Cancer Control Supplements of the National Health Interview Survey, a population-based sample survey of all people older than 17 years of age in the United States in 1987. Of 44,123 adults questioned, 1593 said they had a nonskin cancer. In 1987, after adjustments, the overall prevalence rate of all types of cancer, excluding nonmelanoma skin cancer, was 3230 per 100,000 adults; the rates for men and women were 1930 and 4412, respectively. The authors estimate that, in 1987, 5.7 million adults in the United States were survivors of nonskin cancer, 3.3% of the adult population. Approximately 89,000 adults had cancer during childhood, or 1.6% of the total. Approximately 3.6 million people were at least 5-year survivors and 900,000 adults had their disease diagnosed during the year before interview. Despite the potential for underreporting and misclassification, these national estimates are in general accord with figures estimated from other sources. Increasing survival after cancer, especially childhood and adolescent cancer, indicates the importance of continued monitoring to provide information needed to plan for adequate health services.

Despite extensive study of breast cancer incidence, including specific studies of the relationship between age and breast cancer incidence, the picture remains confusing. This article examines not only the relationship between age and breast cancer, but also trends over time related to this relationship to discern the underlying true age-incidence pattern. The age-incidence curve changes around the menopausal period, most likely due to hormonal changes 10 to 15 years earlier, flattens out in the 40 to 50 year old age range, and then increases as age increases. Recent data showing decreased risk of breast cancer incidence at older ages, e.g., older than 75 years of age, relative to younger ages, are likely an artifact of recent increases in breast cancer screening in the United States. This picture is consistent with increases in screening and with notions of lead time created by increased screening. The increase in screening that has changed the age-incidence relationship may eventually deliver benefits to United States women in terms of mortality deficits, but this is not guaranteed unless screening becomes routine practice and high-quality therapeutic intervention and follow-up occurs as well.

Background: The decline in death rates from cervical cancer in the United States has been widely attributed to the use of Papanicolaou (Pap) smears for early detection of cervical cancer., Methods: Pap smear screening rates, beliefs about appropriate screening intervals and factors affecting screening were examined using 1987 National Health Interview Survey data., Results: Results indicate that through age 69, Blacks are screened at similar or higher rates than Whites. Hispanics, particularly those speaking only or mostly Spanish, are least likely to have received a Pap smear within the last three years. Of women who had never heard of or never had a Pap smear, nearly 80 percent reported contact with a medical practitioner in the past two years, while more than 90 percent reported a contact in the past five years. Overall, the most frequently reported reason for not having a recent Pap smear was procrastinating or not believing it was necessary., Conclusions: Thus, in developing screening programs, Hispanics, particularly Spanish speakers, must be targeted. In addition, educational programs should target unscreened women who forego the test due to underestimating its importance, procrastination, or because their medical care provider did not suggest the procedure. Women must be intensively educated that Pap smears should be scheduled routinely to detect asymptomatic cervical cancer.

The Continuous Medicare History Sample File (CMHSF) was used to derive an estimate of the lifetime direct medical expenses attributable to two chronic diseases, lung cancer and female breast cancer. These two cancers are the leading cancer causes of death in men and women in the United States. They inflict large costs on the population, both direct and indirect, but the costs have been difficult to measure. The primary obstacle to quantification is the intermittent and long-term nature of treatment for these diseases. A complete record of expenses cannot usually be obtained from one source, however, a review of all the national health surveys, as well as the Medicare statistical files identified the CMHSF, which is maintained by the Health Care Financing Administration in a format suitable for calculation of cumulative medical expenses. Some of the pertinent features of the CMHSF include the following: 1) it is a nationally representative sample of the Medicare population, 2) it is longitudinal covering an 8-year period from 1974 to 1981, 3) it captures the majority of medical expenses for each enrollee, and 4) it can be linked to other national data bases such as the National Death Index. Charges for three phases of cancer treatment were derived from the file: initial therapy, maintenance care, and terminal care. A method is described for computing the present value of life-time treatment costs from the phase-specific charges. The lifetime cost of treating breast cancer in 1984 dollars is $36,926 and lung cancer is $12,510.

We examined the association between prostatic cancer incidence rates and the rates of transurethral prostatectomy to explore reasons for the nationally reported dramatic increases in incidence rates of prostatic cancer from 1973 through 1986. There was a strong correlation between both incidence of all stages of prostatic cancer combined and of localized disease and the increasing use of transurethral resection, a common surgical procedure usually performed to relieve urinary obstruction due to benign enlargement of the prostate. Our analyses suggest that increased detection of existing tumors via transurethral resection was the primary reason for the observed increase in incidence rates of prostatic cancer. However, analyses of mortality trends, particularly among nonwhites, and laboratory studies of the histologic nature of clinically asymptomatic tumors suggest that part of the increase may reflect changes in the real risk of prostatic cancer.

Data based on the 1987 National Health Interview Survey are presented depicting factors associated with the knowledge and use of three tests for the early detection of colorectal and prostate cancer: digital rectal examination, fecal occult blood tests, and flexible sigmoidoscopy. The percentage of the at risk adult population who have ever heard of or had these tests is reported. The association of demographic, personal resource, and health system factors with knowledge of these tests is explored using multivariate logistic regression. Health system factors are most consistently associated with use of the tests and with knowledge. Family income, family size, education, knowledge of cancer early warning signs, and measures of encounters with the health care system are associated both with knowledge of and, independent of knowledge, with use of the tests. Residency in the non-South, being white or female, and having an optimistic attitude about cancer prevention are all factors associated with greater knowledge of the tests, but not greater use among those aware of the tests. Membership in a health maintenance organization is more strongly associated with knowledge and use of fecal occult blood tests than the other tests. No association was found between current smoking status and knowledge of or use of any of the tests.

Utilization of health and mental health services by non-institutionalized persons aged 18 years and older is examined based on interviews with probability samples of 3,000 to 3,500 persons in each of three sites of the National Institute of Mental Health Epidemiologic Catchment Area (ECA) program: New Haven, Conn, Baltimore, and St Louis. In all three ECAs, 6% to 7% of the adults made a visit during the prior six months for mental health reasons; proportions were considerably higher among persons with recent DSM-III disorders covered by the Diagnostic Interview Schedule (DIS) or severe cognitive impairment. Between 24% and 38% of all ambulatory visits by persons with DIS disorders were to mental health specialists. In seeking mental health services, men were more likely to turn to the specialty sector than to the generalist; women used both sectors about equally. The aged infrequently received care from mental health specialists. Visits for mental health reasons varied considerably depending on specific types of DIS disorder.

With shrinking federal resources, innovative approaches involving both professional organizations and federal program staff are needed to stimulate research in new or undeveloped clinical areas. National Institute of Mental Health staff and members of the American Psychiatric Association's task force on cost-effectiveness in consultation-liaison psychiatry applied a collaborative model, the research development workshop, to stimulate outcome research in consultation-liaison psychiatry, a field with little previous such research. As a result 12 grant proposals have been submitted to NIMH for review in the last three years, and six are now funded. In contrast, in the previous ten fiscal years none of the nearly 700 services research proposals focused on the consultation-liaison area. The model could be applied to other mental health fields in which research should be stimulated.

Twenty-four hour recall data from adults interviewed in the Second National Health and Nutrition Examination Survey, NHANES II, were used as the basis to estimate total dietary fiber intake in the United States. Food fiber values were calculated for the 2500 foods in NHANES II in two ways: 1) using fiber values compiled from the literature by NCI and 2) values based on the Southgate methodology. Mean dietary fiber intake in the US adult population (greater than 19 y of age) is 11.1 g/d using the first set of values and 13.3 g/d according to Southgate values. On a per 1000 kcal basis, women consume more dietary fiber (6.5 g/1000 kcal) than men (5.5 g/1000 kcal) at every age. Fiber intake by geographic region, age, race, and sex is discussed. Our study indicates that dietary fiber intake in the United States is considerably lower than that previously reported.

The growing evidence linking dietary patterns to the incidence and prevention of chronic disease has prompted a number of prominent health and scientific agencies to publish dietary guidelines for the public. Some dietary guidelines address specific diseases, such as cancer or heart disease; others focus on overall health promotion. This situation has created a demand for nutrition education and information programs for the public. Increasingly, supermarkets are seen as potential sites for effective consumer education. Eat for Health is a joint research study by the National Cancer Institute (NCI) and Giant Food Inc., a regional supermarket chain in the Washington-Baltimore area. The study's goal was to test the feasibility of supermarkets as a site for consumer nutrition education. Eat for Health's educational focus was diet and cancer control issues in the context of dietary patterns that promote health. Particular attention was paid to reduction of fat intake and increases in consumption of dietary fiber from grains, vegetables, and fruits. Analysis of program results is currently underway; data should be available in early 1990.

This paper is an analysis of data on symptoms of depression in a nationwide sample of adults, collected during the National Center for Health Statistics' first Health and Nutrition Examination Survey. The data are analyzed by a statistical adjustment procedure which assesses the impact of the major sociodemographic variables simultaneously, instead of one by one, which avoids a former major source of confusion. The measure of depression is the Center for Epidemiologic Studies Depression (CES-D) Scale. With the exception of race, the study replicates earlier findings. The adjustment procedure facilitates generalization of the results to other populations which are not demographically comparable, such as to smaller locales in the United States, or to populations defined by some criterion variable. Comparison of results is made with earlier work that used the identical measure of depression in two separate locales.

Lung cancer has been the leading cause of cancer death in the United States for the larger part of this century. Increases in smoking prevalence from the 1900s through the 1950s have resulted in more than 100,000 deaths annually. Because of the changes during the last three decades in smoking prevalence, the decreasing tar content of cigarettes, and the increasing popularity of low-tar cigarettes, trends in lung cancer are difficult to predict. This article presents an analysis of smoking and lung cancer data using an age-period-cohort model for projecting lung cancer mortality through the year 2025. The projections are based on the initial parameterization of the model and on prevention objectives related to smoking behavior established by the National Cancer Institute. It is concluded that the recent trends in lung cancer are unlikely to be affected by changes in cigarette composition and consumption in the near term, but increasing the effectiveness of anti-smoking campaigns can have a considerable effect on lung cancer rates in the more distant future.

The occurrence of multiple primary cancers may reflect common etiologic factors. We investigated the extent to which the diet and cancer hypothesis was supported by data from the Surveillance, Epidemiology, and End Results (SEER) Program on multiple primary associations. Cancers of the colon/rectum and prostate in men, and those of the breast, colon/rectum, and uterine corpus in women, were hypothesized a priori to be diet-related cancers. Of the eight multiple primary associations among diet-related cancers that were possible in men and women, relative risks (RR) of a second diet-related primary cancer developing after a first diet-related primary ranged from 1.06 to 1.43. The lower bound of the 99% confidence intervals (CI) for five of these associations exceeded 1.00, and fell between 0.95 and 0.99 for the other three associations. The observed multiple primary associations were compatible with the existence of common etiologic dietary elements. However, hormonal, immunologic, and medical care factors shared by these malignancies must be considered as alternative explanations for these findings.

We discuss some of the issues emerging from a powerful legislative movement for preventive services over the past three years. During this time an increasing number of states passed, considered, or are currently developing breast cancer screening legislation. Most of these laws require some form of third party payment for mammography or establish breast cancer screening programs. The legislation varies markedly with regard to periodicity of examinations, ages covered, type and extent of third party coverage, dosage regulation, and radiographic equipment standards. This shows a need for common standards. Legislation provides an essential incentive for a public health response to a serious problem, but more than laws are needed. Health care providers and the general public need to be aware and take advantage of the coverage provided as a result of legislation. Moreover, public health officials need to be aware that such legislation may lead to a demand for services that exceeds present capacity to deliver them.

The study assessed the effect of screening for mental disorder by means of the General Health Questionnaire (GHQ) on the rate of detection of mental disorder by fourteen physicians in a primary-care clinic. After completing the GHQ, patients were randomised into control (722 patients) and experimental (730 patients) groups. GHQ results of the experimental group were made available to the physicians; those of the control group were not. Sociodemographic factors influenced the physicians' rate of diagnosis of mental disorders (rates were lower for men, students, and patients with at least a partial college education than in subjects who had a low income, less than 7 years of school, or were widowed) but there was no difference between control and experimental groups (16.8% vs 16.0%). Among patients with a prior diagnosis of a mental disorder, twice as many were found to have mental disorders by the physicians as by the GHQ (70% vs 33%).

Several methods are used to minimize and measure error in the NIMH Epidemiologic Catchment Area program. Sampling methods involve the inclusion of group quarters such as prisons, nursing homes, and mental hospitals in the sample frame and the use of probability sampling throughout. Interviewing, methods include use of identical diagnostic interview protocols, centralized training of interview supervisors, standard instructions to interviewers, and reinterview of a subsample by clinicians. In the area of completion, the methods include a 75% to 80% respondent completion rate, a 95% or greater completion rate for individual questions, use of informant interviews where necessary, and statistical adjustments to correct for low completion rates in some subgroups. Analytic methods include use of a computerized diagnostic algorithm, common estimation formulas on identically formatted data files, and estimation of exact variances that take account of the multistage sample design.

Data from the Epidemiologic Catchment Area study were used to compare the demographic characteristics and psychiatric symptomatology of persons classified into four groups based on source of mental health services: clergy only, mental health specialists only, both clergy and mental health specialists, and neither source. Those receiving services from both clergy and mental health specialists were more likely to have major affective and panic disorders than those who sought services from clergy or mental health specialists only or who sought services from neither. Those in the care of mental health specialists were more likely to have substance abuse disorders. Those in the care of clergy only were as likely as those seeing mental health specialists only to have serious mental disorders. The data make clear the need for formal linkages between clergy and mental health professionals.

Based on data from the five sites of the National Institute of Mental Health-sponsored Epidemiologic Catchment Area (ECA) Program, this paper examines the prevalence of psychiatric disorder among recent medical service users versus nonusers, with a particular focus on affective disorders, substance abuse/dependence, and phobias. The rate of current Diagnostic Interview Schedule (DIS) disorders among medical users in all five ECA sites is 21.7 per cent (slightly higher than general population rates) versus 16.7 per cent among nonusers; there is generally no difference between users and nonusers with past DIS diagnoses. Affective disorders were among the most common mental disorders of medical service users, especially among females, with little variation between sites: females: users: 6.9 per cent to 9.3 per cent, nonusers: 3.4 per cent to 6.4 per cent, and males: users: 3.3 per cent to 6.5 per cent, nonusers: 1.2 per cent to 4.1 per cent. Rates of phobias among persons using medical services are also higher than among nonusers. Substance abuse disorders are at least as common among persons who use medical services (8 per cent to 14 per cent of male users) as among those who do not (9 per cent to 11 per cent of male nonusers). The high rates of affective disorders among women and of substance abuse among male medical service users underscore the need to increase the ability of general medical practitioners to recognize and manage or refer these conditions.