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SB820 – COMMUNITY HEALTH ASSESSMENT Lung Cancer Mortality and Morbidity Assignment 1 A. L. LeClerc 10/4/2011 Population Demographics for the U.S., Massachusetts, Boston, and South Boston: The population of South Boston is less racially and ethnically diverse than the U.S. population as a whole. Fewer resident of South Boston identify as African-American (3%) or Hispanic (7%) than do in the national population (12% African-American, 13% Hispanic). The South Boston population differs most from the general population of Boston, which contains 25% African-American and 14% Hispanic identified individuals, but does resemble more closely the overall racial/ethnic makeup of the state of Massachusetts (5% African-American, 7% Hispanic). However, the population of South Boston is not significantly different than the nationwide or statewide populations in its number of native-born or naturalized U.S. citizens, despite the difference in racial/ethnic demographics. South Boston does, nevertheless, have a greater percentage of citizens (92%) than the city of Boston (84%). The South Boston population is also poorer, on average, than the U.S. and Massachusetts populations. Households with an income less than $20,000 per annum comprise 28% of those in South Boston, but only 22% nationwide and 20% in Massachusetts. In addition, fewer households in South Boston have a household income between $20,000 and $59,999 per annum (39%) than in the U.S. as a whole (45%). The percentage of South Boston households with an income over $59,999 dollars is similar to the U.S. population percentage, but is a marked decrease from the percentage for the state of Massachusetts (41%). In general the household income trends present in South Boston are true for the total Boston city population as well. South Boston also shows lower educational attainment that the Massachusetts and Boston populations. While a greater percentage of the South Boston population (32%) obtain a high school diploma or equivalency than in the Massachusetts (27%) or Boston (20% populations), a lesser percentage of the population goes on to obtain an undergraduate or graduate degree (28%) as compared to the statewide (33%) and citywide (30%) populations. Furthermore, a greater proportion of the South Boston population receives less than a high school education (18%) as compared to the population of Massachusetts (15%). However, the percentage of the population attaining less than a high school education is similar for both South Boston and Boston. On the whole, the breakdown of the South Boston population by educational level is similar on average to that of the nation as a whole, with the exception of a greater proportion of South Boston obtaining a high school diploma and not moving on to some college education. Lastly, a greater percentage of adult individuals in South Boston are current smokers (29%) than in the U.S. (22%), Massachusetts (19%), and Boston (21%). However, since these data do not include information about frequency of smoking behavior, quantity of tobacco products used, former smokers, or smokers who are minors, the full picture and impact of smoking behaviors within these four populations is difficult to ascertain. Lung Cancer Mortality: The population of South Boston has a lung cancer mortality rate (95.53) almost double that of the U.S. (53.36) and Massachusetts (58.54) populations, and more than double that for the city of Boston (43.28). The mortality rate among female-identified individuals in South Boston is 34% less than that for male-identified individuals (75.13 v. 114.57), which is a trend seen also on the U.S. (48.38 v. 64.64), state (53.43 v. 64.04), and city (38.29 v. 48.66) levels. The rate of death due to lung cancer is highest among individuals aged 65-74 years (436.89); however, the mortality rate among individuals 45-54 years of age (205.04) is the greatest increase over national (34.44), state (33.43), and city (39.34) rates. This skewing towards death in older middle age to retirement is not observed in the U.S. or Boston populations, whose highest mortality rates occur in individuals 75-84 years of age (394.12 and 355.25, respectively). The highest rates of lung cancer mortality in Massachusetts occur even later at 85 years and older (384.77). Across all regions from the state level downward, the highest mortality rates are seen in individuals with the educational attainment of a high school diploma (178.81, Mass.; 175.56, Bos.; 269.54, S. Bos.). In either direction of lesser or greater education, the mortality rate decreases sharply, with the lowest values observed in those with a college or graduate degree (38.50, Mass.; 24.58, Bos.; 16.26, S. Bos.). The racial/ethnic breakdown of mortality in South Boston follows the general trend of increased mortality due to lung cancer for the area. The mortality rate for individuals who identify as white (99.79) is nearly two times that seen on the national (65.62), state (65.14), and municipal (57.64) level. However, the largest increases in mortality rate are among African-American and Asian identified members of the population. African-American individuals in South Boston (102.04) have two to three times the mortality rate than those in the U.S. (47.56), Massachusetts (38.43), or Boston (37.53) populations. The Asian population in South Boston shows a similar trend with three to four times the mortality rate compared with populations on a larger scale – 83.89 v. 25.57, 22.44, and 20.16 respectively. Given the relatively low diversity of the South Boston population, it is unsurprising that levels of mortality for American-Indian and Hispanic individuals are not observable over the five year period depicted in the table. The Accompanying Questions : 1. Please list at least three Healthy People 2020 Objectives related to your health outcome of interest (Lung Cancer). C-2: Reduce the lung cancer death rate. C-12: Increase the number of central, population-based registries from the 50 states and the District of Columbia that capture case information on at least 95% of the expected number of reportable cancers. C13: Increase the proportion of cancer survivors who are living 5 years or longer after diagnosis. C14: Increase the mental and physical health-related quality of life of cancer survivors. 2. What is the baseline mortality for your health outcome listed in Healthy People 2020? Where did Healthy People 2020 get that number? Can you identify any potential flaws in those data sources that are important to think about? Baseline Mortality for lung cancer: 50.6 lung cancer deaths per 100,000 population occurred in 2007 (age adjusted to the year 2000 standard population). Mortality Data Sources: National Vital Statistics System (NVSS), CDC, NCHS The mortality rate reported by the NVSS and quoted by HP2020 is generated from data collected at the state and local levels via death certificates. The death certificates are prepared by attending physicians and medical examiners (in the case of violent death). Though there are adequate written instructions on how to prepare a death certificate properly provided by the NVSS, there remain many opportunities for simple errors or mistaken assumptions which could skew data. For example, the physician is asked to complete information regarding race/ethnicity, marital status, and whether tobacco was a contributing factor to death, among other information. The reporting of accurate information for these variables thus requires up to date and accurate medical records, as well as availability of information via the medical record. As has happened in the past, it may be likely that in the event race/ethnicity is not designated on the medical record, the physician completing the death certificate may enter a “selfdetermined” value, which is not in fact correct for the patient. 3. What is the target mortality listed in Healthy People 2020? 45.5 deaths per 100,000 population (10% reduction over the baseline listed above). 4. Is Massachusetts doing better or worse than the baseline mortality from HP2020? Is Boston doing better or worse? Massachusetts lung cancer mortality: 52.2 lung cancer deaths per 100,000 population occurred in 2007 (age-adjusted). Thus, Massachusetts is doing slightly worse than the baseline national mortality from HP2020 with 1.6 more deaths due to lung cancer per 100,000 people. Boston lung cancer mortality: 38.9 lung cancer deaths per 100,000 population occurred in 2007 (calculated using the Boston Population Total of the 2000 National Census). Given these data, Boston is doing much better (25% fewer deaths per 100,000 population) than the baseline mortality from HP2020. 5. Do you think it is reasonable for your neighborhood to meet the target goal by 2020? (Calculate neighborhood mortality first and use calculation to answer). South Boston lung cancer mortality by year (1995 – 1999): Year Count Rate 1995 34 113.6 1996 39 130.3 1997 42 140.3 1998 23 76.8 1999 26 86.8 South Boston lung cancer mortality over 5 years (1995-1999): 547.8 deaths per 100,000, which averages to 109.6 deaths per 100,000 per year. Given that the lung cancer mortality rate for 1999 is approximately 1.7 fold higher than the baseline (50.2 deaths per 100,000) reported by Healthy People 2020, reducing the South Boston lung cancer mortality rate to the nationwide target of 45.5 deaths per 100,000 would involve halving the mortality rate for 1999. Since Healthy People 2020, but virtue of its designated target mortality value, assumes that a 10% decrease in mortality over 10 years is feasible, the needed 50% decrease over 20 years for South Boston does not seem feasible. Granted, as is shown above for 1998, halving the lung cancer mortality rate is not an unprecedented occurrence. However, It seems unlikely that a second reduction of the same size would occur without significant input of resources into interventions - 1992 saw the creation of the Massachusetts Tobacco Control Program, while a 1999 regulation provided for all state tobacco settlement revenue to be donated to tobacco control programs - and further restrictions on tobacco sale, advertisement, and cost. 6. Is your health outcome the #1 cause of death in the U.S.? What rank cause of death is your health outcome for the U.S.? No, lung cancer is not the first leading cause of death in the U.S. It is, however, a subset of the second leading cause of death in the U.S., malignant neoplasms or all cancers. Cardiovascular disease is the #1 leading cause of death in the U.S. Lung Cancer Morbidity – Incidence: Before a comparison of the incidence of lung cancer in the South Boston population to that of the larger national, statewide, or city-wide population can be made, several caveats must be admitted regarding the data collection and calculations. First, incidence values for the total U.S. population per 100,000 persons were available via the National Cancer Institute’s SEER program, which includes data from 13 nationwide cancer registries for the years 1992-2008. However, raw counts of total new cases of lung cancer were not available via SEER. In the table, I have reverse calculated estimated raw counts given the demographics of the U.S. population for each subcategory. However, since the rates obtained from SEER were age-adjusted, the total estimated count of new lung cancer cases in each demographic subcategory do not total the estimated total number of new lung cancer cases for the U.S. population as a whole. Thus, the total counts of new lung cancer cases for the U.S. should not be used for comparison, but the incidence value per 100,000 persons given, as it is more accurate. Second, with the exception of the U.S. population incidence values (obtained directly from SEER and not calculated), all other incidences were calculated without subtracting the prevalent cases of lung cancer from the total population, as prevalence values were not obtainable for the state and city level. Hence, the incidences listed in table 3 are inevitably skewed toward lesser values than actual values for the populations. And lastly, the raw count of cases of lung cancer for the neighborhood level of South Boston were obtained via hospital discharge records, and thus do not necessarily represent initial diagnoses of lung cancer, but may also include individuals who have been diagnosed previously. As such, values calculated for South Boston may not in fact be incidences but prevalences. With these caveats in mind, the general trend of lung cancer morbidity for South Boston mirrors that seen for lung cancer mortality. While the incidences of lung cancer for the state (75.32) and city (62.87) levels are similar to the national level (60.78), the incidence for South Boston is more than four times the national incidence (271.23). The pattern of increased morbidity in male-identified versus female-identified individuals seen across the national (77.16 v. 48.84,) state (163.71 v. 146.59,) and municipal (135.48 v. 117.30) levels is not recapitulated on the neighborhood level for South Boston (253.49 for male v. 286.73 for female.) As neighborhood-level figures are more accurately prevalences, they may not reflect an increase in lung cancer incidence among female-identified individuals, but an increase in survivorship among them, as suggested by the lesser mortality rate for female versus maleidentified individuals in South Boston. The age distribution of the highest incidence of lung cancer among the population of South Boston is similar to age at which the highest mortality is seen, 65 – 75 years (1485.44) and 75-84 years (1297.86) of age. Unlike the mortality rate, the incidence of lung cancer among individuals in South Boston aged 45-64 years does not sharply and suddenly increase to a value half that of individuals aged 65-75. This shows that there is some increased mortality in individuals who are younger versus individuals who are older, because despite a lower incidence of lung cancer, there is a greater mortality rate. Unsurprisingly, the incidence of lung cancer for all age groups in South Boston (271.23) is approximately four times that seen on the state (75.32) and city (62.87) level. Direct comparisons of incidence are difficult to make between the neighborhood and national level, given the age distributions used by the cancer registry on the national level. Nevertheless, given that the national incidence of lung cancer for the population aged 65-74 years is 313.89 per 100,000 people and the figure for the same age group in South Boston is 1485.44 per 100,000, a general trend of increased incidence for South Boston as compared to the U.S. can be cautiously inferred. The incidence of lung cancer in South Boston is also higher than in the U.S., state, and city populations in all racial/ethnic groups with the exception of African-Americans. The incidence of lung cancer among white-identified individuals in South Boston (293.99) is nearly five times that of the nation (61.50) and almost four times that of Massachusetts (83.99) and Boston (84.63), while the incidence among Asian and Hispanic individuals is twice that seen in the national, state, and city populations. The incidence among African-American individuals (20.41), however, is nearly one-fourth that seen in the U.S. population (77.98) and half that seen in the Massachusetts (44.08) and Boston (48.93) populations. This trend is most likely accounted for by the general small size of the African-American population within South Boston as mentioned in the demographic profile of the region. Burden Statement: Morbidity and Mortality due to lung cancer is a serious problem within the population of South Boston. For almost every demographic category, be it sex, race/ethnicity, or age, the morbidity and/or mortality due to lung cancer is at least twice that seen on the national, state, or city level. Unlike other areas of Boston, South Boston is not significantly racially/ethnically diverse, which means that whiteidentified individuals are the most affected by lung cancer is in the South Boston population. The general low socio-economic status and educational attainment for South Boston also points to a focus of disease burden on individuals with a high school education or less and with an average annual household income of $59,000 or less. Furthermore, while lung cancer incidence in South Boston (more likely termed prevalence given the data source) is quite high among individuals over 65 years of age, lung cancer mortality begins to peak starting as early as 45 years of age. Similarly, male-identified individuals in South Boston have a much higher rate of death due to lung cancer than incidence of lung cancer when compared to women who show the reverse trend of increased incidence over death. These discrepancies between morbidity and mortality rates suggests that individuals in South Boston who are younger or male-identified may not be receiving lung cancer diagnosis at a rate similar to older or female-identified individuals, in turn leading to diagnosis and treatment at a more advanced disease stage with the concomitant decrease in favorable prognosis and increased mortality. The high rates of morbidity and mortality among individuals starting at age 45 and older in South Boston creates a substantial and multifaceted burden on all levels of society. The first and most obvious burden of disease is financial. The South Boston population is on average of low socioeconomic status, with the majority of households having an income of 59,000 dollars per annum or less. Given that individuals aged 45 years until retirement age (approx. 67 years) are at their peak earning potential in comparison to younger individuals occupying entry level jobs, high levels of disease and death in this population result in a significant amount of lost wages. Since low socio-economic status is often associated with decreased quality of healthcare coverage, the financial stress of loss of wages can be compounded by physician and hospital bills resulting from cancer treatment. In addition, if the individual who becomes ill is the insurance plan holder, then loss of job due to cancer can result in loss of insurance coverage. Despite the availability of MassHealth, expenses incurred in transition from employee-provided coverage and MassHealth coverage must be paid out of pocket first with reimbursement occurring later. For many lower-income households, even this temporary financial strain is enough to put the family in danger of food insecurity or homelessness. High rates of mortality also impart a significant financial burden apart from the loss of wages of the individual who has died. Funeral costs are quite high on average, and individuals below retirement age rarely if ever begin planning for (or paying for) funeral arrangements. Thus, at the time of death, families of those dead from lung cancer may find themselves facing not just significant hospital bills, but also bills associated with the family member’s death itself. On a less family-oriented level, the decreased income from lost wages, hospital bills, or funeral bills also affects the community. The less “disposable” income available to residents in an area, the less local businesses thrive, which results in businesses moving out of a non-lucrative area. Houses owned in the area are also less likely to be well-maintained or renovated due to lack of financial resources to do so. Both of these results lead to a general lowering of the property values of a neighborhood region, which can lead to decreased funding for local services such education, fire and police forces, and some free medical care via community clinics. The burden of high levels of lung cancer morbidity and mortality also effects the psychological welfare and development of families and communities. Returning again to the low socio-economic status of South Boston, it is unlikely that sufficient financial resources are available for out-of-home caretakers for those ill with lung cancer. Family members would be the likely caregivers, placing additional psychological burden on those individuals already managing the grief associated with having a severely ill family member. Hence, increased health problems related to managing high levels of stress, such as substance abuse (shown in Boston BRFSS data,) would likely be seen in the population. Families caring for an individual diagnosed with cancer are also unlikely to have time for much other than working or caregiving. Children in such an environment are thus far less likely to receive adequate emotional and psychological support, which can result in poor school performance and dropout. This may be reflected in the low levels of educational attainment above high school graduation among the population of South Boston. On a community level, if a large percentage of families are busy caring for an ill family member, there is little time for community-level interaction and cohesion outside of the home. Community members and neighbors become more isolated and involvement and investment in the community can decrease. Communities in which there is such atomization become deficient in the social support that buffers the psychological welfare of families caring for those battling cancer. As mentioned above, this can also feed into increased individual stress levels and lead to negative coping behavior such as substance abuse. The high percentage of adults who smoke tobacco in the South Boston population may be in light of this not only contributing to the high rates of lung cancer morbidity and mortality, but negatively coping with the current burden of lung cancer in their community. References 1. U.S. Census Bureau. (July 2002). U.S. Summary 2000. Retrieved September 21, 2011, from http://www.census.gov/prod/2002pubs/c2kprof00-us.pdf. 2. U.S. Census Bureau. (August 2002). Massachusetts: 2000 (Census 2000 Profile). Retrieved September 23, 2011, from http://www.census.gov/prod/2002pubs/c2kprof00-ma.pdf. 3. U.S. Census Bureau. (April 2000). Profile of General Demographic Characteristics: 2000 (Geographic Area: Boston City, Massachusetts). Retrieved September 23, 2011, from http://factfinder.census.gov/servlet/QTTable?_bm=n&_lang=en&qr_name=DEC_2000_SF1_U_DP1&ds_ name=DEC_2000_SF1_U&geo_id=16000US2507000. 4. Boston Redevelopment Authority (December 15, 2003). South Boston: 2000 Census of Population and Housing. Retrieved September 17, 2011, from http://www.bostonredevelopmentauthority.org/PDF/ResearchPublications//573SBoston.pdf. 5. Centers for Disease Control and Prevention (2006). Behavioral Risk Factor Surveillance System Survey Data. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. 6. Boston Public Health Commission (April 12, 2006). Health Status Report for South Boston. Retrieved September 30, 2011, from http://www.bphc.org/about/Documents/Health%20Status%20Report%20for%20South%20Boston.pdf. 7. Centers for Disease Control and Prevention, National Center for Health Statistics. Health United States 2009: With Special Feature on Medical Technology. Hyattsville, Maryland. 2010; pp 476-480. 8. Massachusetts Cancer Registry. Cancer Incidence and Mortality in Massachusetts. Retrieved on September 27, 2011, using MassCHIP software from http://www.mass.gov/dph/masschip. 9. National Cancer Institute, Surveillance Epidemiology and End Results (April 2011). Cancer Statistics: Fast Stats. Retrieved September 27, 2011, from http://seer.cancer.gov/faststats/selections.php?series=cancer. 10. Boston University Medical Center. Hospital Discharge Data: Major Health Outcome of Lung Cancer by Zip Code (02127). Retrieved September 27, 2011 from http://dccwww.bumc.bu.edu/HDD.