New York State Oral Cancer Partnership Jayanth V. Kumar, DDS MPH New York State Department of Health Gustavo D. Cruz, DDS, MPH New York University College of Dentistry 1
Objectives Develop an organizational infrastructure Conduct needs assessment Develop interventions for testing in Phase II 2
Charge Guide the development of a statewide partnership Develop the mechanisms for providing assistance in public relation messages and skills building sessions on strengthening partnership and coalitions Address the strategies for action recommended in the proceedings of the National Strategic Planning Conference for the Prevention and Control of Oral and Pharyngeal Cancer. Specifically, the steering committee will examine the relevance, opportunities and barriers for implementation Examine the potential for implementing various interventions and the likely support for these interventions and their success.
Planning Model PRECEDE ( predisposing, reinforcing and enabling constructs in educational/ecological diagnosis and evaluation) PROCEED (policy, regulatory, and organizational constructs in educational and environmental development) 4
Social assessment Obtain evidence to support the following social concerns about oral cancer: Oral cancer morbidity Delay in diagnosis Poor survival Facial disfigurement Cost to the society Slow and painful death 5
Social assessment Obtain evidence to support the following social concerns about oral cancer: Epidemiological assessment Assess the following contributing causes of the social concerns: Delay in diagnosis Access to care Utilization of dental services Affecting sites in the mouth that are not visible Lack of early detection techniques in dental and medical offices Lower socioeconomic level Lower literacy level Race/Ethnicity 6
Behavioral assessment Explore the reasons for the behavior Knowledge of risk factors Knowledge of oral cancer Awareness among health care professionals regarding the magnitude of the problem Failure to conduct screenings for oral cancer Failure to conduct screenings for oral cancer Oral health is not an integral part of overall health Rates of screening for oral cancer Utilization of dental services Educational assessment The role of following suspected causes of behavior will be studied: Predisposing factors: Lack of knowledge that tobacco and alcohol cause oral cancer Lack of awareness of signs and symptoms of oral cancer Lack of knowledge that oral cancer examinations are easy and needed Enabling factors Inability to pay for dental visits Lack of knowledge among health care providers regarding oral cancer examinations Inability to bill for services Laws, practice acts, and policies Reinforcing factors: Health providers Training programs 7
Ecological analysis Analysis to be undertaken to plan interventions at the following levels: Intrapersonal perception about susceptibility perceived benefits and barriers Interpersonal low level of dental care utilization low rates of compliance with guidelines for examinations Organizational health insurance coverage support of top management Community availability of resources accessibility of health services Public Policy integrate oral health into overall health 8
Specific Aims Plan and develop a partnership Analyze epidemiological data on morbidity and mortality. Conduct an assessment of cancer diagnosis by various health care professionals and the stage in which oral cancers are diagnosed. 9
Specific Aims Assess the general public s knowledge, opinions, and practices about oral cancer prevention and early detection. Conduct a survey of New York State health care professionals to assess the knowledge, opinions, and practices about oral cancer. Evaluate the types of educational materials available to the public and health professionals 10
Specific Aims Conduct qualitative research using focus groups of dentists and cancer patients, physician interviews, and case studies to clarify the opinions, attitudes and practices about oral cancer. 11
Figure 1. Trends in incidence of cancers of oral cavity and pharynx. New York State Cancer Registry, 1983-1997. 30 Rate per 100,000 25 20 15 10 5 0 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 White Males Black Males All Males White Females Black Females All Females 12
Figure 2. Trends in mortality of cancers of oral cavity and pharynx. New York State Cancer Registry, 1983-1997 13 Rate per 100,000 14 12 10 8 6 4 2 0 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 White Males Black Males All Males White Females Black Females All Females
Figure 3. Average annual number of cases of cancers of oral cavity and pharynx by site. New York State Cancer Registry, 1993-1997. 500 450 400 350 300 250 200 150 100 50 0 Tongue Gum and other mouth Salivary Glands Tonsil Hypopharynx Floor of mouth Nasopharynx Oropharynx Lip Other 14
Figure 4. Oral cancer cases diagnosed at early stage by year according to race and gender. New York State Cancer Registry, 1983-1997 100 80 Percent 60 40 20 0 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 15 White Males White Females Black Males Black Females
Oral Cancer Risk Factors 2.95 million adults are cigarette smokers 611,600 adults smoke cigarette and use alcohol in combination 71,600 adults at high risk because of cigarette and alcohol use in combination had no dental or medical visit in the past year 16
Hospitalization: SPARCS There were 2798 discharges where oral cancer was indicated as a diagnosis (ICD codes 140-146, 149) There were 1461 discharges with oral or pharyngeal cancer as a principal diagnosis The average length of stay was 10 days The average hospital charge was $26,202
Hospital Discharges by Selected Characteristics Gender Age Race Ethnicity Characteristics Male Female <45 46-64 65 Plus Whites Others Hispanic Others All Diagnoses (%) N= 2798 66.5 33.5 11.5 43.0 45.5 60.2 39.8 6.9 93.1 Principal Diagnosis (%) N= 1461 64.8 35.2 11.8 43.7 44.5 61.3 38.7 5.9 94.1
SOURCE OF PAYMENT Source Self-pay Medicare Medicaid Blue Cross Commercial Other All Diagnoses(%) 2.9 38.1 17.5 12.4 24.3 4.7 Principal Diagnoses(%) 3.4 37.7 14.8 12.9 26.6 4.7
Length of Stay and Total Charges All Diagnoses Principal Diagnosis Length of Stay (DAYS) Mean Median Charges Mean Median Mode Range 9.5 (11.8) 6 $22,394 $13,197 $11,900 $15 - $404,600 10.4 (13.4) 7 $26,202 $16,060 $5180 $15 - $404,600
Site of the cancer in hospitalized patients 210 299 67 28 197 117 543 Tongue Floor Salivary Gland Gum Oropharynx Others Lip 21
Ten Most Commonly Performed Procedures ALL PROCEDURES Radical neck dissection Tracheostomy Enteral nutrition Partial glossectomy Excision Gastrostomy Laryngoscopy Partial mandibulectomy Free skin graft Injection of antibiotic PRINCIPAL PROCEDURES Tracheostomy Partial glossectomy Radical neck dissection Excision Complete sialoadenectomy Partial sialoadenectomy Gastrostomy Partial mandibulectomy Partial ostectomy of facial bone
The LOGISTIC Procedure: Odds Ratios and 95% Confidence Intervals for Length of Stay Greater than 6 days Variable Odds Confidence Limits Ratio Lower Upper GENDER (Male) 1.4 1.1 1.8 PAYMENT SOURCE 1.2 1.0 1.5 TYPE OF CANCER 5.1 3.6 7.3 RACE (Non White) 1.4 1.1 2.0 AGE (45+) 2.1 1.4 3.2 CO-MORBIDITY 3.1 2.1 4.5 NOTE: Payment source = Medicaid & Medicare vs. all others; Type of Cancers = All other cancers vs. lip & salivary gland Co-morbidity = Having another diagnosis
Discussion Based on the analysis of existing data, should the partnership represent high-risk areas (groups) or all residents of New York? Should the partnership focus intervention on highrisk areas (groups) or all residents of New York?
Cancer Incidence by Region, 1999 2500 2000 1500 1000 500 0 677.2 410.6 266.6 1272.4 743.8 528.6 NYC Rest of State ALL Males Females 25
Cancer Incidence per 100,000 by Age Groups, 1995-1999 60 50 40 30 20 10 0 54.4 39.2 25.6 10.8 13.6 1.6 1.2 3.9 20-34 35-49 50-64 65+ Males Females 26
Cancer Incidence per 100,000 by Race and Hispanic Origin, 1995-1999 25 20 15 14.5 19.1 13.7 16.6 10 5 6.2 6.3 6.3 4.1 0 Males Females Whites African Americans Asians Hispanic Origin 27
Age-adjusted cancer rates males Legend ca_data1.age_adj 1 0.0-4.4 4.5-7.6 7.7-12.7 females
Cancer cases 5-yr average Legend ca_data1.ca_count_m 1.0-18.0 18.1-57.8 57.9-160.0 males Legend ca_data1.ca_count_f 0.0-13.8 13.9-41.8 41.9-77.4 females
Early Diagnosis Legend ca_data1.early_dx_m males Legend ca_data1.early_dx_f females 0.0-26.9 0.0-38.1 27.0-42.9 38.2-57.1 43.0-66.7 57.2-100.0
Drinking & Smoking Legend ca_data1.chronic 1 0.0-2.3 2.4-6.7 6.8-21.4 Legend ca_data1.current 1 14.3-25.0 25.1-37.9 38.0-50.0 High Risk Alcohol Consumption Current Smoking
This map shows the ranking of counties by a total of 6 indicators: male rates & late Dx, female rates & late Dx, Smoking & Drinking Legend combofile2.tot_rank / <NONE> 79.0000000-157.000000 157.000001-217.000000 217.000001-298.000000