Photo Illustration by Lois Bergerson/UW SMPH Media Solutions Trends in Cancer CONS IN IS Disparities between W s and s in Wisconsin July 214 Carbone Cancer Center Dane County Cancer Profile 214 UNIVERSITY OF WISCONSIN SCHOOL OF MEDICINE AND PUBLIC HEALTH
TABLE OF CONTENTS Overview... 1 Key Findings... 2 Wisconsin Cancer Disparities Report Card... 4 Implications... 5 Limitations... 5 Results... 6 All Cancer Sites... 7 Breast Cancer... 13 Colorectal Cancer... 15 Lung Cancer... 21 Prostate Cancer... 27 Data Sources... 29 Methods... 31 References... 34 Appendix: Racial Diversity in Wisconsin... 36 Funding for this report was provided by the University of Wisconsin Carbone Cancer Center (P3 CA1452). We gratefully acknowledge input and feedback from Amy Godecker, PhD, University of Wisconsin Carbone Cancer Center Survey Research Shared Resource, and Mary Foote, MS, Epidemiologist, Wisconsin Cancer Reporting System, Department of Health Services. Suggested Citation: Williamson A, McDonald J, Prince R, Strickland R, Bailey E, Linskens B, Adams A. Trends in Cancer Disparities between s and s in Wisconsin. Madison, WI: University of Wisconsin Carbone Cancer Center, Cancer Health Disparities Initiative; 214. Trends in Cancer Disparities between s and s in Wisconsin
OVERVIEW Cancer incidence and mortality have decreased over the last few decades, 1,2 yet nationally and in Wisconsin, not all people have benefited equally from these successes. 3,4 This has exacerbated disparities in cancer burden between various population groups, including those defined by race. The purpose of this report is to provide information about trends in cancer incidence (new diagnoses) and mortality (deaths) for s and s in Wisconsin over the period 1995-21 and to highlight disparities in the cancer burden between these populations. Monitoring trends in cancer incidence and mortality is an important part of any effort to reduce disparities. This information is useful to community organizations, advocates, clinicians, policy makers and researchers who seek to reduce the burden of cancer. The report focuses on incidence and mortality for all cancers and for the four most commonly diagnosed cancers in Wisconsin: lung, colon, breast and prostate. Together, these four cancers accounted for 54% of all newly diagnosed cancer cases during the period 1995-21. 5 Wisconsin s racial and ethnic minority populations are of relatively small size and tend to be geographically clustered. (See Appendix.) Consequently, in these populations rates of rare events, like cancer, can fluctuate greatly from year to year for reasons other than an actual change in the underlying frequency of the disease. One strategy for producing stable estimates for rates of rare events within small populations is to pool several years of data. This methodology has been used in previously published reports on cancer disparities in Wisconsin. 6-12 The present report uses a different approach and examines trends in annual rates over a 16-year period. The authors previously used The population of five Wisconsin counties comprises 89% of the state population this approach when examining similar data for the period 1995-24/25. 13,14 The current report is limited to a comparison between s and s due to data limitations resulting from the relatively small size of other minority populations in the state. Cancer incidence and mortality data were obtained from the Wisconsin Cancer Reporting System (see Data Sources). Trends in rates over the period 1995-21 for s and s were calculated and changes in relative disparity were measured (see Methods). This report is an update to a 29 University of Wisconsin Carbone Cancer Center Cancer Health Disparities Initiative report which included data through 24/25. 13 Trends in Cancer Disparities between s and s in Wisconsin 1
KEY FINDINGS Trends in cancer incidence and mortality for s and s by cancer site and sex are included in Results. This section presents key findings. Disparities in cancer incidence and mortality between s and s in Wisconsin persisted over the period 1995 21. In most cases, s had consistently higher rates of new cancers and cancer deaths than s. Incidence rates for ranged from being 15% higher than s (all site cancer for both sexes combined) to 73% higher (male lung cancer) in 21. Mortality rates for s ranged from being 31% higher than s (female all site cancer) to 75% higher (prostate cancer, male lung cancer) in 21. There were some exceptions. Breast cancer incidence rates were lower for s than for s over virtually the entire period. There was also little difference in all site cancer incidence rates between and women. And for colorectal cancer for men and for both sexes combined, incidence was higher for s in the early years of the period. Disparities Persist: Trends in All Site Cancer Incidence and Mortality Wisconsin, 1995 21 Age Adjusted Rate per 1, 6 5 4 3 2 1 Incidence Incidence Mortality Mortality The impact of these disparities on human lives cannot be underestimated. In 21, 192 cancer deaths would have been avoided if s had experienced the lower age specific cancer mortality rates of s. This represents more than one third of cancer deaths that year. Trends in Cancer Disparities between s and s in Wisconsin 2
Excess Deaths per 1 People Wisconsin, 21 For every 1 s lost to cancer in 21, 36 of those deaths could have been prevented if s had experienced the same cancer death rates as s Image created at iconarray.com. Risk Science Center and Center for Bioethics and Social Sciences in Medicine, University of Michigan. Accessed June 11, 214. For some cancer sites, disparities have increased over time. Despite efforts to reduce them, disparities in cancer incidence and mortality have increased over the last 16 years for several cancer sites. The increases were particularly large for colorectal cancer incidence and mortality and for breast cancer mortality. But for some other cancer sites, there has been progress in reducing disparities. Over the period 1995-21, there was notable progress in reducing disparities in lung cancer incidence for both men and women as well as lung, prostate and all site cancer mortality for men. Trends in Cancer Disparities between s and s in Wisconsin 3
WISCONSIN CANCER DISPARITIES REPORT CARD Site ALL CANCERS Both sexes Female Male BREAST COLORECTAL LUNG INCIDENCE Change in Disparity Disparity Both sexes Female Male Both sexes Female Male PROSTATE MORTALITY Change in Disparity Disparity Disparity Key: AA rates > W rates in all years Change in Disparity Key: Slight improvement in disparity AA rates > W rates in most years Improvement in disparity W rates > AA rates in all years No general pattern of disparity AA = ; W = Slight worsening of disparity Worsening of disparity No change in disparity Trends in Cancer Disparities between s and s in Wisconsin 4
IMPLICATIONS Persistent and in many cases increasing disparities in cancer incidence and mortality between s and s in Wisconsin were observed over the period 1995-21. The causes of these disparities are complex and multifactorial. Other studies have shown that the factors which contribute to disparities between racial groups include socioeconomic status (SES) and the relationship of SES to access to prevention, screening and treatment, lack of health insurance, language and literacy barriers and quality of care. 15-22 (SES is based primarily on a person s income, education level and occupation.) The Wisconsin Cancer Reporting System, like most public health data systems, does not collect SES, let alone measures of access to and quality of care. Therefore, this report is unable to examine the causes of the racial disparities that were observed. Wisconsin s report card on racial cancer disparities indicates that much work remains to be done to achieve the goal of reducing or eliminating disparities (see Healthiest Wisconsin 22 23 ). There are many evidencebased strategies to reduce cancer health disparities for groups defined by race, ethnicity, SES and geography (where you live). 3,24,25 These interventions target points across the cancer spectrum, from prevention to palliative care, in community settings as well as health care. 26-28 Other strategies focus on changing the social determinants of health, 29-31 addressing the conditions in which people are born, grow, live, work and age. 32 Eliminating cancer disparities in Wisconsin will require sustained effort by communities, health systems, nonprofit organizations, foundations, policy makers, researchers and others, working collaboratively for greatest impact. 31,33 LIMITATIONS This study is subject to limitations. First, as noted above, without information about SES, access to care and quality of care for cases in the state cancer registry, we were unable to examine the causes of the racial disparities we observed and the extent to which they are explained by differences in these factors. Countylevel SES could be assigned to each registry case. However, with large variability in SES within a county, county-level analyses of the relationship between SES and cancer rates can produce misleading results. 22 Second, the scope of this report is limited to differences in cancer incidence and mortality between and s in Wisconsin. The decision to focus on these two groups was determined by the demographic composition of Wisconsin and the rarity of cancer events. Wisconsin has relatively small non- populations, making comparisons similar to those featured in this report difficult to replicate among other racial/ethnic groups. Third, although s form the largest minority population in Wisconsin, there are still relatively few new cases and cancer deaths for some organ sites among this racial group. This yields rates for s that vary more from year to year than rates. Our approach for dealing with this variability was to measure disparities based on trends in rates rather than raw rates in any given year. Trends in Cancer Disparities between s and s in Wisconsin 5
RESULTS Trends in Cancer Disparities between s and s in Wisconsin 6
Age-Adjusted Incidence Rates per 1, 7 6 5 4 3 2 1 ALL CANCER SITES MALE & FEMALE Rate Trend Rate Trend Year Incidence Rate* INCIDENCE Trends in Age-Adjusted Cancer Incidence, All Sites, By Race Wisconsin, 1995-21 Incidence Rate Trend* / 1995 522.8 471.9 553.7 488.9 1.13 21 527.4 451.8 524.4 456.2 1.15 * Rates are age-adjusted per 1, population. Trends were fitted from ordinary least squares regression of rates. In 21, 28,541 people in Wisconsin were diagnosed with cancer. The number of new cancer cases per 1, population (incidence) decreased 7% between 1995 and 21, from 476.4 per 1, to 444.8 per 1,. The four most frequently occurring cancers were prostate (3,931 cases); breast (3,894); lung (3,849); and colorectal (2,387). Is there a disparity between s and s? Yes. Over the entire period 1995-21, cancer incidence rates were higher for s than s. In 1995 this meant that there were 65 more new cancer cases per 1, people for s than s. In 21, the difference was 68 new cancer cases per 1, people. Between 1995 and 21, the disparity in cancer incidence rates between s and s increased slightly. The ratio between and rates was 1.13 in 1995 and 1.15 in 21. When considering all cancers, the disparity in incidence between s and s in Wisconsin persists and has in fact worsened somewhat. In 21, this meant that s were 15% more likely to be diagnosed with cancer than s. 7
ALL CANCER SITES FEMALE INCIDENCE Trends in Age-Adjusted Cancer Incidence, All Sites, Females, By Race Wisconsin, 1995-21 In 21, 13,68 women in Wisconsin were diagnosed with cancer. The number of new cancer cases per 1, women (incidence) decreased 2.7% between 1995 and 21, from 414.2 per 1, to 43.1 per 1,. Age-Adjusted Incidence Rate per 1, 5 45 4 35 3 25 2 15 1 5 Rate Trend Rate Trend Is there a disparity between s and s? There was not a general pattern of disparity over the period 1995-21. Incidence rates for and women were similar in many years. Over the period 1995-21, cancer incidence rates for women increased slightly while rates among women decreased slightly. This resulted in a small increase in disparity in cancer incidence rates between and women. The ratio between and rates was.97 in 1995 and 1.4 in 21. Year Incidence Rate* Incidence Rate Trend* / 1995 386.5 411.9 413.5 426.5.97 21 433.5 411.7 431.8 414.5 1.4 * Rates are age-adjusted per 1, population. Trends were fitted from ordinary least squares regression of rates. When considering all cancers, there has been little difference in incidence between and women in Wisconsin. It is too soon to say whether the disparity observed in 21 will persist. 8
ALL CANCER SITES MALE INCIDENCE Trends in Age-Adjusted Cancer Incidence, All Sites, Males, By Race Wisconsin, 1995-21 In 21, 14,861 men in Wisconsin were diagnosed with cancer. The number of new cancer cases per 1, population (incidence) decreased 13% between 1995 and 21, from 573.7 per 1, to 51.7 per 1,. Age-Adjusted Incidence Rate per 1, 9 8 7 6 5 4 3 2 1 Rate Trend Rate Trend Is there a disparity between s and s? Yes. Over the entire period 1995-21, incidence rates were higher for men than men. In 1995 this meant that there were 178 more new cancer cases per 1, for men compared to men. In 21, the difference was 142 new cancer cases per 1, men. Between 1995 and 21, the disparity in cancer incidence rates between s and s decreased slightly. The ratio between and rates was 1.31 in 1995 and 1.28 in 21. Year Incidence Rate* Incidence Rate Trend* / 1995 731.3 566.3 763.3 584.9 1.31 21 658.8 57.7 655. 512.5 1.28 * Rates are age-adjusted per 1, population. Trends were fitted from ordinary least squares regression of rates. When considering all cancers, the disparity in incidence between and men in Wisconsin has improved somewhat. However, a large gap persists. In 21, men had a 28% higher chance of being diagnosed with cancer than men. 9
Age-Adjusted Mortality Rate per 1, 35 3 25 2 15 1 5 ALL CANCER SITES MALE & FEMALE MORTALITY Trends in Age-Adjusted Cancer Mortality, All Sites, By Race Wisconsin, 1995-21 Rate Trend Rate Trend In 21, 11,279 people in Wisconsin died from cancer. The number of cancer deaths per 1, population (mortality rate) decreased 13% between 1995 and 21, from 2.5 per 1, to 173.7 per 1,. Is there a disparity between s and s? Yes. Over the entire period 1995-21, cancer mortality rates were higher for s than s. In 1995 this meant that there were 77 more cancer deaths per 1, people for s than s. In 21 the difference was 64 cancer deaths per 1, people. If s experienced the lower age-specific mortality rates of s, about one in three cancer deaths in 1995 and 21 would have been avoided. Between 1995 and 21, the disparity in cancer incidence rates between s and s decreased slightly. The ratio between and rates was 1.39 in 1995 and 1.37 in 21. Year Mortality Rate* Mortality Rate Trend* / Actual Excess^ Excess/Actual Deaths Deaths Deaths 1995 276.5 198.4 276.5 199.3 1.39 351 125 36% 21 243.9 171.4 233.6 17. 1.37 528 192 36% * Rates are age-adjusted per 1, population. Trends were fitted from ordinary least squares regression of rates. ^ Excess deaths = the number of deaths averted if the cancer mortality rate were lowered to the cancer mortality rate. See Appendix for complete methodology. 1 When considering all cancers, the disparity in cancer death rates between s and s in Wisconsin has improved somewhat. However, a large gap persists, translating into 192 excess cancer deaths among s in 21 alone.
Age-Adjusted Mortality Rate per 1, 25 2 15 1 5 ALL CANCER SITES FEMALE MORTALITY Trends in Age-Adjusted Cancer Mortality, All Sites, Females, By Race Wisconsin, 1995-21 Rate Trend Rate Trend In 21, 5,361 women in Wisconsin died from cancer. The number of cancer deaths per 1, women (mortality rate) decreased 1% between 1995 and 21, from 164.5 per 1, to 147.7 per 1,. Is there a disparity between s and s? Yes. Over the entire period 1995-21, cancer mortality rates were higher for women than women. In 1995 this meant that there were 37 more cancer deaths per 1, for women compared to s. In 21 the difference was 45 cancer deaths per 1, women. If women experienced the lower agespecific mortality rates of women, about one in three cancer deaths in 1995 and 21 would have been avoided. Between 1995 and 21, the disparity in cancer death rates between and women increased slightly. The ratio between and rates was 1.22 in 1995 and 1.31 in 21. Year Mortality Rate* Mortality Rate Trend* / Actual Excess^ Excess/Actual Deaths Deaths Deaths 1995 195.8 163.6 22.3 165.5 1.22 147 47 32% 21 21.1 145.8 191.1 145.9 1.31 252 87 34% * Rates are age-adjusted per 1, population. Trends were fitted from ordinary least squares regression of rates. ^ Excess deaths = the number of deaths averted if the cancer mortality rate were lowered to the cancer mortality rate. See Appendix for complete methodology. 11 When considering all cancers, the disparity in death rates between and women in Wisconsin has worsened somewhat. This translated into 87 excess cancer deaths among women in 21 alone.
Age-Adjusted Mortality Rate per 1, 5 45 4 35 3 25 2 15 1 5 ALL CANCER SITES MALE MORTALITY Trends in Age-Adjusted Cancer Mortality, All Sites, Males, By Race Wisconsin, 1995-21 Rate Trend Rate Trend In 21, 5,918 men in Wisconsin died from cancer. The number of cancer deaths per 1, men (mortality rate) decreased 18% between 1995 and 21, from 257.7 per 1, to 211.2 per 1,. Is there a disparity between s and s? Yes. Over the entire period 1995-21, cancer mortality rates were markedly higher for men than men. In 1995 this meant that there were 145 more cancer deaths per 1, men for s than s. In 21 the difference was 95 cancer deaths per 1, men. If men had the lower age-specific mortality rates of men, about four in 1 cancer deaths in 1995 and 21 would have been avoided. Between 1995 and 21, the disparity in overall cancer incidence between and men decreased. The ratio between and rates was 1.57 in 1995 and 1.46 in 21. Year Mortality Rate* Mortality Rate Trend* / Actual Excess^ Excess/Actual Deaths Deaths Deaths 1995 48.3 254 398. 253.5 1.57 24 94 46% 21 35.3 28.4 3.1 25.1 1.46 276 111 4% * Rates are age-adjusted per 1, population. Trends were fitted from ordinary least squares regression of rates. ^ Excess deaths = the number of deaths averted if the cancer mortality rate were lowered to the cancer mortality rate. See Appendix for complete methodology. 12 When considering all cancers, the disparity in cancer death rates between and men in Wisconsin has improved. However, a large gap persists, translating into 111 excess cancer deaths among men in 21 alone.
Age-Adjusted Incidence Rate per 1, 18 16 14 12 1 8 6 4 2 Rate Trend Rate Trend Year Incidence Rate* BREAST CANCER INCIDENCE Trends in Age-Adjusted Female Breast Cancer Incidence, By Race Wisconsin, 1995-21 Incidence Rate Trend* / 1995 19.7 128.3 117.6 136.4.86 21 116.2 116.9 115.2 122.7.94 * Rates are age-adjusted per 1, population. Trends were fitted from ordinary least squares regression of rates. In 21, 3,894 women in Wisconsin were diagnosed with breast cancer. The number of new breast cancer cases per 1, women (incidence) decreased 8.7% between 1995 and 21, from 128.2 per 1, to 117. per 1,. Is there a disparity between s and s? Yes. Over virtually the entire period 1995-21, the breast cancer incidence rate was lower for women than for women. In 1995 there were 19 fewer new breast cancer cases per 1, for s compared to s. In 21, the difference was 7 new cancer cases per 1, women. Between 1995 and 21, the trend in breast cancer incidence rates stayed relatively constant while rates decreased. As a result, the disparity in breast cancer incidence rates which favored s decreased slightly. The ratio between and rates was.86 in 1995 and.94 in 21. women and women in Wisconsin now have very similar chances of being diagnosed with breast cancer. A key question for the future is will the incidence rates remain the same or, as rates drop, will a disparity develop in which incidence exceeds incidence? 13
Age-Adjusted Mortality Rate per 1, 4 35 3 25 2 15 1 5 BREAST CANCER MORTALITY Trends in Age-Adjusted Female Breast Cancer Mortality, By Race Wisconsin, 1995-21 Rate Trend Rate Trend In 21, 767 women in Wisconsin died from breast cancer. The number of breast cancer deaths per 1, women (mortality rate) decreased 28% between 1995 and 21, from 29.6 per 1, to 21.3 per 1,. Is there a disparity between s and s? Yes. Over the entire period 1995-21, the breast cancer mortality rate trend was higher for women than women. In 1995 this meant that there were 3 more breast cancer deaths per 1, women for s than s. In 21 the difference grew to 8 cancer deaths per 1, women. Between 1995 and 21, the disparity in breast cancer mortality rates between and women increased. The ratio between and rates was 1.9 in 1995 and 1.38 in 21. Year Mortality Rate* Mortality Rate Trend* / 1995 33.5 29.5 3.9 28.4 1.9 21 35.3 2.9 27.6 19.9 1.38 * Rates are age-adjusted per 1, population. Trends were fitted from ordinary least squares regression of rates. The disparity in breast cancer death rates between and women in Wisconsin has worsened. By 21, this meant that women were 38% more likely to die from breast cancer than women. 14
COLORECTAL CANCER MALE & FEMALE INCIDENCE Trends in Age-Adjusted Colorectal Cancer Incidence, By Race Wisconsin, 1995-21 In 21, 2,387 people in Wisconsin were diagnosed with colorectal cancer. The number of new colorectal cancer cases per 1, people (incidence) decreased 39% between 1995 and 21, from 6.2 per 1, to 37. per 1,. Age-Adjusted Incidence Rate per 1, 8 7 6 5 4 3 2 1 Rate Trend Rate Trend Is there a disparity between s and s? At the beginning of the period 1995-21, colorectal cancer incidence rates for s were less than or similar to that of s. But from 1997 onward, the incidence rate for s was higher than that of s. By 21, there were 18 more new colorectal cancer cases per 1, for s compared to s. Between 1995 and 21, the disparity in colorectal cancer incidence rates between s and s increased dramatically. The ratio between and rates was.99 in 1995 and 1.46 in 21. Year Incidence Rate* Incidence Rate Trend* / 1995 48.3 59.9 63.3 63.8.99 21 6.1 35.5 57.4 39.4 1.46 * Rates are age-adjusted per 1, population. Trends were fitted from ordinary least squares regression of rates. As colorectal cancer incidence among s has dropped steadily, the disparity in incidence between s and s in Wisconsin has worsened markedly. By 21, this meant that s had a 46% higher chance of being diagnosed with colorectal cancer than s. 15
COLORECTAL CANCER FEMALE INCIDENCE Trends in Age-Adjusted Colorectal Cancer Incidence, Females, By Race Wisconsin, 1995-21 In 21, 1,161 women in Wisconsin were diagnosed with colorectal cancer. The number of new colorectal cancer cases per 1, women (incidence) decreased 38% between 1995 and 21, from 51.8 per 1, to 32.3 per 1,. Age-Adjusted Incidence Rate per 1, 1 9 8 7 6 5 4 3 2 1 Rate Trend Rate Trend Is there a disparity between s and s? Yes. Colorectal cancer incidence rates were higher for women than women in nearly every year in the period 1995-21. By 21, there were 16 more new colorectal cancer cases per 1, for women compared to women. Between 1995 and 21, the disparity in colorectal cancer incidence rates between and women increased dramatically. The ratio between and rates was 1.4 in 1995 and 1.46 in 21. Year Incidence Rate* Incidence Rate Trend* / 1995 41.4 51.5 56.1 53.8 1.4 21 45.6 31.2 51.2 35.1 1.46 * Rates are age-adjusted per 1, population. Trends were fitted from ordinary least squares regression of rates. As colorectal cancer incidence among women has dropped steadily, the disparity between and women in Wisconsin has worsened markedly. By 21, this meant that women had a 46% higher chance of being diagnosed with colorectal cancer than women. 16
COLORECTAL CANCER MALE INCIDENCE Trends in Age-Adjusted Colorectal Cancer Incidence, Males, By Race Wisconsin, 1995-21 In 21, 1,226 men in Wisconsin were diagnosed with colorectal cancer. The number of new colorectal cancer cases per 1, men (incidence) decreased 41% between 1995 and 21, from 71.5 per 1, to 42.4 per 1,. Age-Adjusted Incidence Rate per 1, 1 9 8 7 6 5 4 3 2 1 Rate Trend Rate Trend Year Incidence Rate* Incidence Rate Trend* / 1995 59.8 7.9 72. 76.9.94 21 8.6 4.5 67.7 44.3 1.53 * Rates are age-adjusted per 1, population. Trends were fitted from ordinary least squares regression of rates. Is there a disparity between s and s? Yes. For most years in the period 1995-21, and particularly in the last decade, the colorectal cancer incidence rate was higher for men than men. By 21, there were 23 more new colorectal cancer cases per 1, for men compared to men. Between 1995 and 21, the disparity in colorectal cancer incidence rates between and men increased dramatically. The ratio between and rates was.94 in 1995 and 1.53 in 21. As colorectal cancer incidence among men has dropped steadily, the disparity between and men in Wisconsin has worsened markedly. In 21, this meant that men had a 53% higher chance of being diagnosed with cancer than men. 17
COLORECTAL CANCER MALE & FEMALE MORTALITY Trends in Age-Adjusted Colorectal Cancer Mortality, By Race Wisconsin, 1995-21 In 21, 939 people in Wisconsin died from colorectal cancer. The number of colorectal cancer deaths per 1, population (mortality rate) decreased 35% between 1995 and 21, from 22.3 per 1, to 14.4 per 1,. Age-Adjusted Mortality Rate per 1, 4 35 3 25 2 15 1 5 Rate Trend Rate Trend Is there a disparity between s and s? Yes. Over the entire period 1995-21, the colorectal cancer mortality rate trend was higher for s than s. In 1995 this meant that there were 5 more colorectal cancer deaths per 1, for s than s. In 21 the difference was 8 cancer deaths per 1,. Between 1995 and 21, the disparity in colorectal cancer mortality rates between s and s increased. The ratio between and rates was 1.22 in 1995 and 1.62 in 21. Year Mortality Rate* Mortality Rate Trend* / 1995 19.4 22.4 27.2 22.4 1.22 21 21.5 14.3 22.2 13.7 1.62 * Rates are age-adjusted per 1, population. Trends were fitted from ordinary least squares regression of rates. While deaths due to colorectal cancer are dropping for both groups, the disparity in rates between s and s in Wisconsin has worsened. By 21, this meant that s were 62% more likely to die from colorectal cancer than s. 18
COLORECTAL CANCER FEMALE MORTALITY Trends in Age-Adjusted Colorectal Cancer Mortality, Females, By Race Wisconsin, 1995-21 In 21, 454 women in Wisconsin died from colorectal cancer. The number of colorectal cancer deaths per 1, women (mortality rate) decreased 35% between 1995 and 21, from 18.7 per 1, to 12.1 per 1,. Age-Adjusted Mortality Rate per 1, 4 35 3 25 2 15 1 5 Rate Trend Rate Trend Is there a disparity between s and s? Yes. Over the entire period 1995-21, the colorectal cancer mortality rate trend was higher for women than women. In 1995 this meant that there were 5 more colorectal cancer deaths per 1, women for s than s. In 21 the difference was 8 cancer deaths per 1, women. Between 1995 and 21, the disparity in colorectal cancer mortality rates between and women increased dramatically. The ratio between and rates was 1.25 in 1995 and 1.69 in 21. Year Mortality Rate* Mortality Rate Trend* / 1995 15.7 18.8 23.1 18.4 1.25 21 17.1 12. 19.7 11.7 1.69 * Rates are age-adjusted per 1, population. Trends were fitted from ordinary least squares regression of rates. The disparity in colorectal cancer death rates between and women in Wisconsin has worsened markedly. By 21, this meant that women were 69% more likely to die from colorectal cancer than women. 19
COLORECTAL CANCER MALE MORTALITY In 21, 485 men in Wisconsin died from colorectal cancer. Trends in Age-Adjusted Colorectal Cancer Mortality, Males, By Race Wisconsin, 1995-21 The number of colorectal cancer deaths per 1, men (mortality rate) decreased 36% between 1995 and 21, from 27.4 per 1, to 17.5 per 1,. Age-Adjusted Mortality Rate per 1, 5 45 4 35 3 25 2 15 1 5 Rate Trend Rate Trend Is there a disparity between s and s? Yes. Over the entire period 1995-21, the colorectal cancer mortality rate trend was higher for men than men. In 1995 this meant that there were 7 more colorectal cancer deaths per 1, men for s than s. In 21 the difference was 1 cancer deaths per 1, men. Between 1995 and 21, the disparity in colorectal cancer mortality rates between and men increased. The ratio between and rates was 1.24 in 1995 and 1.62 in 21. Year Mortality Rate* Mortality Rate Trend* / While deaths due to colorectal cancer are dropping for both groups, the disparity in rates between and men in Wisconsin has worsened. 1995 26.4 27.4 34.5 27.8 1.24 21 28.7 17.4 26.5 16.4 1.62 * Rates are age-adjusted per 1, population. Trends were fitted from ordinary least squares regression of rates. By 21, this meant that men were 62% more likely to die from colorectal cancer than men. 2
Age-Adjusted Incidence Rate per 1, 14 12 1 8 6 4 2 LUNG CANCER MALE & FEMALE INCIDENCE Trends in Age-Adjusted Lung Cancer Incidence, By Race Wisconsin, 1995-21 Rate Trend Rate Trend In 21, 3,849 people in Wisconsin were diagnosed with lung cancer. The number of new lung cancer cases per 1, population (incidence) decreased 5.5% between 1995 and 21, from 63.6 per 1, to 6.1 per 1,. Is there a disparity between s and s? Yes. Over the entire period 1995-21, lung cancer incidence rates were higher for s than s. In 1995 this meant that there were 41 more new lung cancer cases per 1, for s compared to s. In 21, the difference was 28 new lung cancer cases per 1, people. Between 1995 and 21, the disparity in lung cancer incidence rates between s and s decreased. The ratio between and rates was 1.62 in 1995 and 1.47 in 21. Year Incidence Rate* Incidence Rate Trend* / 1995 14.9 62.1 16.4 65.8 1.62 21 91.5 58.2 87.3 59.3 1.47 * Rates are age-adjusted per 1, population. Trends were fitted from ordinary least squares regression of rates. As lung cancer incidence rates for s have dropped steadily, the disparity in incidence between s and s in Wisconsin has improved. However, a large gap persists. In 21 s had a 47% higher chance of being diagnosed with lung cancer than s. 21
LUNG CANCER FEMALE INCIDENCE Trends in Age-Adjusted Lung Cancer Incidence, Females, By Race Wisconsin, 1995-21 In 21, 1,753 women in Wisconsin were diagnosed with lung cancer. The number of new lung cancer cases per 1, women (incidence) increased 12% between 1995 and 21, from 46.5 per 1, to 52. per 1,. Age-Adjusted Incidence Rate per 1, 1 9 8 7 6 5 4 3 2 1 Rate Trend Rate Trend Is there a disparity between s and s? Yes. In all but one year during the period 1995-21, lung cancer incidence rates were higher for women than women. In 1995 this meant that there were 17 more new lung cancer cases per 1, for women compared to women. In 21, the difference was 13 new cancer cases per 1, women. Between 1995 and 21, the disparity in lung cancer incidence rates between and women decreased. The ratio between and rates was 1.35 in 1995 and 1.25 in 21. Year Incidence Rate* Incidence Rate Trend* / 1995 61.8 45.7 65.9 48.6 1.35 21 76.7 5.7 66.7 53.3 1.25 * Rates are age-adjusted per 1, population. Trends were fitted from ordinary least squares regression of rates. The disparity in lung cancer incidence between and women in Wisconsin has improved. However, a large gap persists. In 21 women had a 25% higher chance of being diagnosed with lung cancer than women. 22
LUNG CANCER MALE INCIDENCE Trends in Age-Adjusted Lung Cancer Incidence, Males, By Race Wisconsin, 1995-21 In 21, 2,54 men in Wisconsin were diagnosed with lung cancer. The number of new lung cancer cases per 1, men (incidence) decreased 19% between 1995 and 21, from 87.1 per 1, to 7.9 per 1,. Age-Adjusted Incidence Rate per 1, 2 18 16 14 12 1 8 6 4 2 Rate Trend Rate Trend Is there a disparity between s and s? Yes. Over the entire period 1995-21, lung cancer incidence rates were higher for men than men. In 1995 this meant that there were 78 more new lung cancer cases per 1, for men compared to men. In 21, the difference was 49 new lung cancer cases per 1, men. Between 1995 and 21, the disparity in lung cancer incidence rates between and men decreased. The ratio between and rates was 1.87 in 1995 and 1.73 in 21. Year Incidence Rate* Incidence Rate Trend* / 1995 169. 84.8 168.2 89.8 1.87 21 112.6 68.3 116.9 67.5 1.73 * Rates are age-adjusted per 1, population. Trends were fitted from ordinary least squares regression of rates. As lung cancer incidence rates for men have dropped steadily, the disparity in incidence between s and s in Wisconsin has improved. However, a very large gap persists. In 21 men had a 73% higher chance of being diagnosed with lung cancer than men. 23
Age-Adjusted Mortality Rate per 1, 1 9 8 7 6 5 4 3 2 1 LUNG CANCER MALE & FEMALE MORTALITY Trends in Age-Adjusted Lung Cancer Mortality, By Race Wisconsin, 1995-21 Rate Trend Rate Trend In 21, 2,971 people in Wisconsin died from lung cancer. The number of lung cancer deaths per 1, population (mortality rate) decreased 5% between 1995 and 21, from 48.5 per 1, to 46.2 per 1,. Is there a disparity between s and s? Yes. Over the entire period 1995-21, lung cancer mortality rates were markedly higher for s than s. In 1995 this meant that there were 34 more lung cancer deaths per 1, for s compared to s. In 21 the difference was 24 cancer deaths per 1, people. Between 1995 and 21, the disparity in lung cancer mortality rates between s and s decreased. The ratio between and rates was 1.7 in 1995 and 1.53 in 21. Mortality Rate* Mortality Rate Trend* / 1995 82.1 47.6 83.5 49.2 1.7 21 69.5 45.4 7.1 46. 1.53 * Rates are age-adjusted per 1, population. Trends were fitted from ordinary least squares regression of rates. As lung cancer death rates for s have dropped steadily, the disparity in rates between s and s in Wisconsin has improved. However, a very large gap persists. In 21 s had a 53% higher chance of dying of lung cancer than s. 24
Age-Adjusted Mortality Rate per 1, 7 6 5 4 3 2 1 LUNG CANCER FEMALE MORTALITY Trends in Age-Adjusted Lung Cancer Mortality, Females, By Race Wisconsin, 1995-21 Rate Trend Rate Trend In 21, 1,359 women in Wisconsin died from lung cancer. The number of lung cancer deaths per 1, women (mortality rate) increased 16% between 1995 and 21, from 33.1 per 1, to 38.4 per 1,. Is there a disparity between s and s? Yes. Lung cancer mortality rates were higher for women than women in virtually every year in the period 1995-21. In 1995 this meant that there were 12 more lung cancer deaths per 1, women for s than s. In 21 the difference was 13 cancer deaths per 1, women. Between 1995 and 21, the disparity in lung cancer mortality rates between and women remained constant. The ratio between and rates was 1.33 in both 1995 and 21. Mortality Rate* Mortality Rate Trend* / 1995 38.5 32.9 46.9 35.2 1.33 21 47.7 38. 51.3 38.7 1.33 * Rates are age-adjusted per 1, population. Trends were fitted from ordinary least squares regression of rates. As lung cancer death rates for both and women in Wisconsin have risen, the disparity in rates between the two groups has persisted. In 21, this meant that women were 33% more likely to die from lung cancer than women. 25
LUNG CANCER MALE MORTALITY Trends in Age-Adjusted Lung Cancer Mortality, Males, By Race Wisconsin, 1995-21 In 21, 1,612 men in Wisconsin died from lung cancer. The number of lung cancer deaths per 1, men (mortality rate) decreased 2% between 1995 and 21, from 7.5 per 1, to 56.7 per 1,. Age-Adjusted Mortality Rate per 1, 18 16 14 12 1 8 6 4 2 Rate Trend Rate Trend Is there a disparity between s and s? Yes. Over the entire period 1995-21, lung cancer mortality rates were markedly higher for men than men. In 1995 this meant that there were 71 more lung cancer deaths per 1, for men than men. In 21 the difference was 42 cancer deaths per 1, men. Between 1995 and 21, the disparity in lung cancer mortality rates between and men decreased. The ratio between and rates was 2.3 in 1995 and 1.75 in 21. Mortality Rate* Mortality Rate Trend* / 1995 149. 68.6 14.7 69.4 2.3 21 12.2 55.3 97.5 55.8 1.75 * Rates are age-adjusted per 1, population. Trends were fitted from ordinary least squares regression of rates. As the lung cancer death rate for men has dropped steadily, the disparity in rates between and men in Wisconsin has improved. However, a very large gap persists. In 21 men had a 75% higher chance of dying of lung cancer than men. 26
Age-Adjusted Incidence Rate per 1, 35 3 25 2 15 1 5 PROSTATE CANCER INCIDENCE Trends in Age-Adjusted Prostate Cancer Incidence, By Race Wisconsin, 1995-21 Rate Trend Rate Trend In 21, 3,931 men in Wisconsin were diagnosed with prostate cancer. The number of new prostate cancer cases per 1, men (incidence) decreased 24% between 1995 and 21, from 165.1 per 1, to 125.4 per 1,. Is there a disparity between s and s? Yes. Over the entire period 1995-21, prostate cancer incidence rates were higher for men than men. In 1995 this meant that there were 17 more new prostate cancer cases per 1, for s compared to s. In 21, the difference was 76 new cases per 1, men. Between 1995 and 21, the disparity in cancer incidence rates between s and s decreased slightly. The ratio between and rates was 1.62 in 1995 and 1.53 in 21. Year Incidence Rate* Incidence Rate Trend* / 1995 257.9 161.7 278.9 172.3 1.62 21 213.1 122.1 218.1 142.3 1.53 * Rates are age-adjusted per 1, population. Trends were fitted from ordinary least squares regression of rates. The disparity in prostate cancer incidence between and men in Wisconsin has improved somewhat. However, a very large gap persists. In 21 men had a 53% higher chance of being diagnosed with prostate cancer than men. 27
Age-Adjusted Mortality Rate per 1, 9 8 7 6 5 4 3 2 1 PROSTATE CANCER MORTALITY Trends in Age-Adjusted Prostate Cancer Mortality, By Race Wisconsin, 1995-21 Rate Trend Rate Trend In 21, 621 men in Wisconsin died from prostate cancer. The number of prostate cancer deaths per 1, men (mortality rate) decreased 38% between 1995 and 21, from 38.4 per 1, to 23.8 per 1,. Is there a disparity between s and s? Yes. Over the entire period 1995-21, prostate cancer mortality rates were significantly higher for men compared to men. In 1995 this meant that there were 32 more prostate cancer deaths per 1, men for s than s. In 21 the difference was 17 cancer deaths per 1, men. Between 1995 and 21, the disparity in prostate cancer mortality rates between and men decreased. The ratio between and rates was 1.86 in 1995 and 1.75 in 21. Year Mortality Rate* Mortality Rate Trend* / 1995 69.1 37.9 68.2 36.7 1.86 21 32. 23.7 38.7 22.1 1.75 * Rates are age-adjusted per 1, population. Trends were fitted from ordinary least squares regression of rates. The disparity in prostate cancer death rates between and men in Wisconsin has improved. However, a very large gap persists. In 21 men had a 75% higher chance of dying from prostate cancer than men. 28
DATA SOURCES Incidence data Cancer incidence is defined as the number of new cancer cases that occur during a specified period for a population at risk for developing the disease. Incidence is expressed as a number of cases or as a rate (the number of cases per 1, persons). This report details the occurrence of new cancers among Wisconsin residents during the period 1995-21 as reported by the Wisconsin Cancer Reporting System (WCRS). WCRS is a population-based registry guided by statutory mandate to collect, manage and analyze all cancer cases for Wisconsin residents. The registry is located in the Division of Public Health, Wisconsin Department of Health Services. WCRS was established in 1976 to collect cancer incidence data of Wisconsin residents as mandated by Wisconsin Statute 255.4, Cancer Reporting. In compliance with state law, hospitals, physicians and clinics report cancer cases to WCRS. All tumors with malignant cell types are reportable to WCRS, except basal cell and squamous cell carcinomas of the skin and in situ cervical cancer. With the passage of the Cancer Registries Amendment Act (Public Law 12-515) in 1994, WCRS became part of the National Program of Cancer Registries. WCRS cancer incidence data were obtained from the Wisconsin Interactive Statistics on Health (WISH) Cancer Module, available for public use at http://www.dhs.wisconsin.gov/wish/cancer/. Data were accessed on April 23, 213. Subsequent data releases add additional years of data as well as newly identified cases to previously reported years, changing the reported rates. Mortality data Cancer mortality is defined as deaths from cancer that occur during a specified period of time for a particular population. Mortality is expressed as a number of deaths or as a rate (the number of deaths per 1, persons). This report details cancer deaths among Wisconsin residents during the period 1995-21 as reported by WCRS. WCRS obtains these data from the National Center for Health Statistics in the Centers for Disease Control and Prevention. This data source codes underlying cause of death using the International Classification of Diseases (ICD). Cancer deaths were defined as those coded 14. through 28.9 in ICD-9 (up to 1998) and C through C97 in ICD-1 (after 1998). WCRS cancer mortality data were obtained from the Wisconsin Interactive Statistics on Health (WISH) Cancer Module, available for public use at http://www.dhs.wisconsin.gov/wish/cancer/. Data were accessed on April 23, 213. Subsequent data releases add additional years of data as well as newly identified cases to previously reported years, changing the reported rates. Trends in Cancer Disparities between s and s in Wisconsin 29
Cancer types Cancers are named after the part of the body where they originate. The cancer types covered in this report are: All sites (all cancers regardless of type) Breast (female) Colorectal Lung (lung and bronchus) Prostate Breast, colorectal, lung and prostate are the four most common cancers. Race definition The methodology for defining race developed by the National Center for Health Statistics and the U.S. Census Bureau was modified in 27. The National Center for Health Statistics recoded detailed historical race information into four major categories to make the race information compatible with available annual population estimates used as denominators for the rates. These categories are, Black or, Indian/Alaska Native and Asian or Pacific Islander. For a more detailed description of race variables, please refer to the National Center for Health Statistics and U.S. Census Bureau documentation. 34,35 Age standardization All rates presented in this report are age-adjusted by WCRS using the 2 U.S. standard population. Age adjustment of rates allows comparison of populations by eliminating differences in observed rates that result from age differences in underlying populations. Trends in Cancer Disparities between s and s in Wisconsin 3
METHODS Definition of disparities Our analysis follows the National Cancer Institutes definition of cancer health disparities as differences in the incidence, prevalence, mortality, and burden of cancer and related adverse health conditions that exist among specific population groups in the United States. 36 Specifically, we measured disparities as differences in the incidence and mortality of cancer between s and s. Measure of relative disparity We used the rate ratio to measure relative disparity. Since the report involves only comparisons between two groups ( s and s), this pairwise measure of relative disparity is sufficient. 37 For both incidence and mortality, the rate ratio is defined as the ratio of the rate to the rate in a given year. To measure change in relative disparity, we compared the ratio for the first and last year in the period of analysis. Trends vs. observed rates There is a relatively small population of s in Wisconsin (see Appendix). This can make it difficult to obtain stable estimates for rates of less common cancers in this population. To address this problem, other reports on cancer health disparities in Wisconsin have pooled several years of data. 6-12 This report used an alternative approach by comparing trends in annual rates over a 16-year period. Specifically, we calculated the least squares regression (the best fit straight line) of the rates over the years 1995-21 and graphed the resulting smoothed trend line. The trend line reflects movements in rates occurring over the entire period while minimizing the fluctuation in any given year that may be due to small population sizes. (Notably, because of the larger population size, the trend line closely matches the actual rates in any given year.) In measures of disparity, we use the rate from the trend line rather than the observed rate to measure incidence or mortality in a given year. Again, this reflects changes in disparities over time while minimizing the fluctuation in the rate ratio in any given year due to small population sizes. Calculation of excess mortality One way to express the extent of racial cancer disparities is to pose a hypothetical situation in which s experience the same cancer mortality rates observed among s. Using this method, we calculated simulated deaths by multiplying the age-specific mortality rates observed among s by the population in each age group. The ratio of the difference between observed and modeled deaths to observed deaths among s is an estimate of excess mortality, or deaths that would have been avoided if s had experienced the lower age-specific death rates of s. We calculated excess deaths for all site cancer only, as the number of cases for specific cancer sites was too small to permit meaningful analysis. Trends in Cancer Disparities between s and s in Wisconsin 31
Table 1 (next page) provides an example for all cancers in males and females in 1995. Column 1 shows the age-specific cancer death rates observed among s in each 5-year age group. Column 2 shows the number of cancer deaths observed among s in each 5-year age group. Column 3 shows the statewide population in each 5-year age group. Column 4 shows the age-specific death rate for s calculated by dividing column 2 by column 3. There were 351 deaths caused by cancer in Wisconsin in 1995. Column 5 shows the number of deaths that would have occurred if s had experienced the same age-specific death rates as s in 1995. These modeled deaths are calculated by multiplying the age-specific mortality rate by the population in each age group. Summing across the age groups, 226 s would have died from cancer in 1995 if the population had experienced the cancer death rates. The difference between the observed and modeled deaths among s was 125 deaths, thus 36% (125/351) of deaths would have been averted if s had experienced the lower age-specific death rates of s. Trends in Cancer Disparities between s and s in Wisconsin 32
Table 1: Calculation of Excess Cancer Deaths: All Cancer Sites, Male & Female, Wisconsin, 1995 Age Observed Death Rate (per 1,) (Column 1) Observed Number of Deaths (Column 2) Population^ (Column 3) Observed Death Rate (per 1,) (2)/(3) (Column 4) Modeled Deaths (if exposed to Rate) (1)*(3) (Column 5) Less than 1 6,722.. 1-4 1 1 28,254 3.5.3 5-9 1 1 34,312 2.9.3 1-14 2.8 31,374..9 15-17 1 17,649..2 18-19 9,273.. 2-24 1 1 21,639 4.6.2 25-29 1 1 21,919 4.6.2 3-34 1 1 23,746 4.2.2 35-39 1 1 23,623 4.2.2 4-44 41.6 24 18,817 127.5 7.8 45-49 83.1 23 14,28 161.9 11.8 5-54 156.7 35 9,28 377.2 14.5 55-59 292.7 36 7,573 475.4 22.2 6-64 447.7 43 6,384 673.6 28.6 65-69 7.9 52 5,475 949.8 38.4 7-74 956.7 44 3,423 1,285.4 32.7 75-79 124.7 37 2,28 1,675.7 27.4 8-84 1485.2 24 1,252 1,916.9 18.6 85+ 188.3 21 1,12 1,875. 21.1 Total 351 288,251 226 Source: Wisconsin Cancer Registry System. Wisconsin Department of Health Services, Division of Public Health, Office of Health Informatics. Wisconsin Interactive Statistics on Health (WISH) data query system, Cancer module. http://www.dhs.wisconsin.gov/wish/cancer/. Accessed June 5, 213. WCRS suppresses values if there are less than 1 (but more than zero) observed deaths in an age category. For the excess death analysis, in those instances the rate or number of deaths was given the value of 1, resulting in a conservative estimate of excess mortality. ^ Source: Wisconsin Department of Health Services. Wisconsin Interactive Statistics on Health (WISH) data query system, Population module. http://www.dhs.wisconsin.gov/wish/main/wis_pop/wis_pop_home.htm. Accessed June 5, 213. Sum among all age groups. Difference from sum of observed number of deaths by age group listed in table due to suppressed values. Trends in Cancer Disparities between s and s in Wisconsin 33
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APPENDIX RACIAL DIVERSITY IN WISCONSIN Compared to other states, Wisconsin does not have large minority populations. Taken together, racial and ethnic minority populations comprise 15.6% of Wisconsin's total population. (See Table A below.) s are the largest minority group, comprising 6.3% of the total population. Nearly 9% of s live in five counties (Milwaukee, Racine, Dane, Kenosha and Rock) and almost two-thirds (66%) reside in the City of Milwaukee. 38 Table A. Wisconsin demographic estimates, by race and ethnicity, 21 Estimate Percent of Total Total 5,686,986 One race 4,92,67 86.2% Black or 359,148 6.3% Indian and Alaska Native 54,526 1.% Asian 129,234 2.3% Native Hawaiian and Other Pacific Islander 1,827.% Some other race 135,867 2.4% Two or more races 14,317 1.8% Hispanic or Latino ethnicity (of any race) 336,56 5.9% Source: U.S. Census Bureau, 21 Census. http://factfinder.census.gov. Accessed December 6, 213. Trends in Cancer Disparities between s and s in Wisconsin 36
Carbone Cancer Center UNIVERSITY OF WISCONSIN SCHOOL OF MEDICINE AND PUBLIC HEALTH Increasing the capacity of communities and the University of Wisconsin Carbone Cancer Center to reduce inequities in cancer burden through research, outreach and education 61 N. Walnut Street, Madison, WI 53726 chdi@uwcarbone.wisc.edu chdi.wisc.edu QUESTIONS OR COMMENTS ABOUT THIS REPORT? Go to http://tinyurl.com/ngkow4r to provide anonymous feedback or email us at chdi@uwcarbone.wisc.edu RESEARCH COMMUNITY OUTREACH EDUCATION