Elsevier

Cancer Epidemiology

Volume 33, Issue 5, November 2009, Pages 319-324
Cancer Epidemiology

Lung cancer incidence trends by histologic type in areas of California vs. other areas in the Surveillance, Epidemiology and End Results Program

https://doi.org/10.1016/j.canep.2009.10.007Get rights and content

Abstract

Background: This study compared temporal trends in incidence rates for the major histological types of lung cancer in areas of California (CA), which started a comprehensive state tobacco control program in 1989, and other selected geographic areas for which data on long-term trends were available. Methods: Age-standardized incidence rates (ASIRs) within age 25–64 years, most likely to have been affected by tobacco control programs, were compared for lung-bronchus adenocarcinoma, squamous cell carcinoma, and small cell carcinoma in 1992–2005 for non-Hispanic whites in three areas of CA in the Surveillance, Epidemiology and End Results (SEER) Program vs. 10 non-CA SEER areas. For 1985–2005, data were available for all whites in the San Francisco-Oakland CA SEER area and eight non-CA SEER areas. Results: ASIRs were roughly similar in CA and non-CA areas in 1992, but declines from 1992 to 2005 were larger in CA than non-CA areas for each histological type. In San Francisco-Oakland CA, declines were not clearly evident from 1985 to 1988 (before the tobacco control program started) but from 1992 to 2005 declines were larger than in the non-CA areas. Conclusions: These findings provide further support for expansion of statewide tobacco control programs, in order to reduce incidence rates for all histologic types of lung cancer.

Introduction

California (CA) established in 1989 the first comprehensive statewide tobacco control program including an increase in the state cigarette tax, but also mandated funding for mass media anti-tobacco campaigns, local support for adherence to antismoking laws, and community-based interventions [1], [2]. The CA program has been associated with larger declines in smoking rates, and in per-capita cigarette consumption, in CA vs. the U.S. exclusive of CA in the 1990s [1]. In national surveys of samples of the general U.S. adult population, “successful” (i.e., 1 year or longer) smoking cessation rates at age 20–64 years increased from 1980 to 1990 but in the 1990s these rates were higher among non-Hispanic white adults age 20–49 years in CA, than in six southern “tobacco growing” states with low cigarette taxes and no statewide program in the 1990s [3]. From 1992–1993 to 2001–2002 smoking prevalence at age 20–64 years in non-Hispanic whites declined significantly in CA but not in the other geographic areas compared [4].

These geographic (i.e., CA vs. non-CA) differences in smoking habits in non-elderly age groups should have resulted in geographic differences in temporal trends in incidence rates for tobacco-related cancers (especially in younger adults) from the 1990s through the early-mid 2000s. Using a 1-year time lag from the start of the CA tobacco control program, age-standardized lung cancer incidence rates fell significantly after 1990 in the San Francisco-Oakland CA area of the National Cancer Institute's Surveillance, Epidemiology and End Results (SEER) Program of high-quality population-based cancer registries, and not in the other SEER areas; data were not analyzed for histologic types of lung cancer [5].

A report from the CA Department of Health Services in 2000 showed that the estimated annual percentage changes in age-adjusted lung-bronchus cancer incidence rate from 1988 through 1997 was −0.4% per year (not significantly different from zero) for eight non-CA SEER areas combined vs. −1.9% per year (p < .01) for the entire state of CA (i.e., including parts of CA not covered by the SEER Program at that time) [6]. These reports [5], [6] did not present data for young adults. Jemal et al. [7], however, showed that lung cancer mortality rates (and trends from 1990–1994 through 1995–1999) at age 30–39 years among 33 U.S. states (including CA) was inversely associated with an index of state tobacco control efforts. Mortality data cannot be used to analyze trends in lung cancer by histologic subgroups, due to the limitations of death certificates; cancer incidence data from high-quality population-based registries must be used.

Declines in lung cancer risk after smoking cessation (relative to current smokers or never smokers) have been shown for each of the major histologic types of lung cancer in men and women, including adenocarcinoma (ADC), small cell lung carcinoma (SCLC), squamous cell carcinoma (SQC) and large cell carcinoma (LCC), in early studies reviewed in a Surgeon General Report [8], a recent meta-analysis [9], and two cohort studies of women in the U.S. [10], [11]. While trends in incidence rates for specific histological types of lung cancer have been reported in the U.S. [12], [13], apparently no reports have examined such rates in U.S geographic areas that have differed in tobacco control efforts. ADC, the most common histologic type, is less strongly associated with current smoking than SQC or SCLC and other specific causal factors for ADC have been suggested [14].

Thus, if declines in incidence rates were larger in CA than non-CA areas for ADC and not the other major histologic types, then explanations other than the CA tobacco control program could be suggested. In contrast, an early divergence (shortly after 1989) of CA from the rest of the U.S. in incidence rates (especially among young adults) for each histologic group would support an impact of CA's comprehensive tobacco control program, and this could provide additional support for expanding comprehensive programs nationally.

The present study examined trends in ASIRs using data from the SEER Program [15]. The focus was on a comparison trends in CA vs. non-CA SEER areas, because of the unique history of comprehensive state tobacco control efforts in CA, its apparent impact on trends in smoking habits in CA [1], [3], [4] and its association with significantly greater declines in mortality from heart disease in CA compared to the rest of the U.S. in the 1990s [16].

Section snippets

Methods

Age-standardized incidence rates (ASIRs) for lung-bronchus cancers by histologic type category in 1992–2005, directly standardized to the U.S. 2000 standard population using 5-year age intervals, were available for 13 SEER areas; the combined population of all 13 areas represents about 14% of the entire U.S. population [15]. The 13 areas are: Atlanta, Georgia, metropolitan area; Detroit, Michigan, Metropolitan area; Connecticut; Hawaii; Iowa; New Mexico; Seattle-Puget Sound, Washington; Los

Three CA SEER areas combined vs. 10 non-CA SEER areas combined

In 1992, ASIRs for age 25–64 years in non-Hispanic whites for selected years (Table 1) showed only small differences between the three California areas and the other 10 SEER areas for all lung-bronchus cancers and for SCLC, SQC and ADC. In 1992, the 95% CIs in the CA and non-CA areas did not overlap only for SQC (with a lower ASIR in the CA areas). From 1992 to 1995, small declines in ASIRs were evident. All of the 95% CIs in ASIRs for CA and non-CA areas overlapped in 1992 and 1995. By 2000,

Discussion

Although declines in ASIRs for lung cancer would have been expected in view of temporal increases in smoking cessation rates in the non-elderly U.S. population [3], the larger declines in CA than non-CA SEER areas for each of the three major histologic types of lung cancer (i.e., not limited to ADC) found in the present study provide further support for a potential impact of tobacco control efforts in CA which started in 1989. Ecologic analyses of trends in ASIRs for ADC in relation to

Conflict of interest statement

None.

Acknowledgments

This work was supported by Contract N01-PC-35133 between the National Cancer Institute and the Connecticut Department of Public Health.

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