How do cancer rates in your area

compare to those in other areas?

Understand the use of standardized

rates, specific rates, and the
limitations of computer mapping
 Rates
Summary rate of the actual number of
Crude observed events in a population over a given
time period (e.g. all cancer deaths in 2000)

Rates for specific segments/groups of

Specific the population (e.g. sex, age, race,
cause of death, cancer site)

Adjusted Rates are standardized to a control

population
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 Crude Rates

 Estimates the burden of disease in a

population

 Not useful for making comparisons between

groups or examining changes over time,
because it depends largely on population
structure

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 Specific Rate
 Important because outcomes may be profoundly
affected by factors such as age, race, and gender

 More precise indicator of risk than a crude rate as

it controls for a particular characteristic of interest

 Allows for comparisons between strata or between

groups

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Examples of Specific Rates

 Age specific rates

 Gender specific rates
 Race specific rates
 Cause specific rates
 Site specific rates

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 Lung Cancer Deaths by Age Group, United States, 1995

Age-Specific
Lung Cancer Lung Cancer Death Rate
Age (years) Population
Deaths
Per 100,000
5-14 38,134,488 11 11 / 38,134,488 = 0.03
15-24 35,946,635 41 41 / 35,946,635 = 0.11
25-34 40,873,139 303 303 / 40,873,139 = 0.74
35-44 42,467,719 2,709 2,709 / 42,467,719 = 6.38
45-54 31,078,760 12,356 12,356 / 31,078,760 = 39.76
Total 188,500,741 15,420 xxx

Cause Specific Rate = (15,420/188,500,741) x 100,000 = 8.18 / 100,000

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 Adjusted Rate
 Specific rates are standardized to a control
population and are summarized to produce an
adjusted rate

 Used to compare rates of entire populations taking

into account differences in population structure
(e.g., age, gender, race or other variables)

 Adjusted rates can be compared if they are

calculated using the same standard population

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Creating a cause-specific, age-adjusted death rate using
direct standardization
1980 U.S. Expected
Cancer Population
Age ASR Standard Number of
Deaths at risk
Population Deaths
(1) (2) (1) / (2) = (3) (4) (1) / (2) x (4) = (5)
0-18 5 5,000 60,500,000
19-64 10 25,000 140,300,000
65+ 100 15,000 25,700,000
Total 115 45,000 xxx 226,500,000

Crude Rate
(115 / 45,000) x 1000
2.56 per 1,000

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Creating a cause-specific, age-adjusted death rate
using direct standardization
1980 U.S. Expected
Cancer Populatio
Age ASR Standard Number of
Deaths n at risk
Population Deaths
(1) (2) (1) / (2) = (3) (4) (3) x (4) = (5)
0-18 5 5,000 1.00 per 1000 60,500,000 60,500
19-64 10 25,000 0.40 per 1000 140,300,000 56,120
65+ 100 15,000 6.67 per 1000 25,700,000 171,419
Total 115 45,000 xxx 226,500,000 288,039

Crude Rate Age-Adjusted Rate

(115 / 45,000) x 1000 (288,039 / 226,500,000) x 1000
2.56 per 1,000 1.27 per 1,000
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Comparing Crude and Age-Adjusted Rates

 If crude rate decreases after adjustment,

the study population is older than the
standard population

 If crude rate increases after adjustment,

the study population is younger than the
standard population

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 Standard Population

 By convention, SEER uses the 1970

US standard population

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 Cancer Death Rates by State per 100,000, 2000
Utah 122 Wisconsin 163 Rhode Island 178
Hawaii 133 Florida 166 South Carolina 178
Colorado 142 Oregon 166 Alabama 179
New Mexico 146 Alaska 167 New Jersey 179
Idaho 148 Texas 168 Ohio 180
Arizona 155 New York 169 Arkansas 181
Nebraska 155 Oklahoma 170 New Hampshire 181
North Dakota 155 Vermont 172 Tennessee 181
South Dakota 155 Michigan 173 Mississippi 182
California 156 Georgia 175 Maryland 184
Minnesota 156 North Carolina 175 Nevada 184
Wyoming 157 Missouri 176 West Virginia 184
Kansas 159 Pennsylvania 177 Maine 185
Montana 159 Virginia 177 Kentucky 192
Iowa 160 Illinois 178 Louisiana 193
Washington 162 Indiana 178 Delaware 195
Connecticut 163 Massachusetts 178 Dist. Of Col. 212

Average annual mortality 1992-1996, age-adjusted to 1970

United States = 170 per 100,000 12
Age-adjusted death rates per 100,000

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14
 Cautions in Comparing Rates

 Precision: Rates calculated from an area with a

small population are subject to a large amount of
variation from year to year

 Comparability: Rates are affected by differences

in population structure (e.g., a county with more
older women may have higher rates for breast
cancer than a county with more younger women)

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 Advanced Topics
 What types of investigations address cancer etiology
and control?

 How do we evaluate whether cancer studies are valid?

 How do we assess whether associations between

cancer and risk factors are causal?

 How much of the morbidity and mortality from cancer

might be prevented by interventions?

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What types of investigations address
cancer etiology and control?

Understand case-control, cohort,

and intervention studies
Descriptive Studies (to generate hypotheses)
 Case-Reports / Series

 Cross-Sectional Studies (Prevalence Studies)

measure exposure and disease at the same time

 Ecological Studies (Correlational Studies) use group

data rather than data on individuals.
These data cannot be used to assess individual risk –
to do so is to commit Ecological Fallacy

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Analytic Studies (to test hypotheses)

 Observational Studies
 Cohort Studies
 Case-Control Studies

 Experimental Studies
 Randomized Control Trials
(RCT / Clinical Trials)

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 Cohort Study Design

 A group of people (cohort) without disease are

identified and characterized by an exposure

 Group is followed forward over a period of

time to observe the development (incidence)
of the disease of interest

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 Single Sample Cohort Study Design

Time

Diseased
Exposed
Not Diseased
Target Disease-Free
Cohort
Population Diseased
Not Exposed
Not Diseased

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 Multi-Sample Cohort Study Design

Time

Diseased
Study Exposed
Cohort
Not Diseased

Diseased
Control Not Exposed
Cohort
Not Diseased

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 Calculating Outcome Measures
Outcome
Disease No Disease
Exposure (cases) (controls) Incidence

Exposed A B IE = A / (A+B)

Not Exposed C D IN = C / (C+D)

Relative Risk = IE / IN

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