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Uhm Phd 9629839 R.Pdf INFORMATION TO USERS This manuscript has been reproduced from the microfilm master. UMI films the text directly from the original or copy submitted. Thus, some thesis and dissertation copies are in typewriter face, while others may be from any type ofcomputer printer. The quality ofthis reproduction is dependent upon the quality ofthe copy submitted. Broken or indistinct print, colored or poor quality illustrations and photographs, print bleedthrough, substandard margins, and improper alignment can adversely affect reproduction. In the unlikely event that the author did not send UMI a complete manuscript and there are missing pages, these will be noted. Also, if unauthorized copyright material had to be removed, a note will indicate the deletion. Oversize materials (e.g., maps, drawings, charts) are reproduced by sectioning the original, beginning at the upper left-hand comer and continuing from left to right in equal sections with small overlaps. Each original is also photographed in one exposure and is included in reduced form at the back ofthe book. Photographs included in the original manuscript have been reproduced xerographically in this copy. Higher quality 6" x 9" black and white photographic prints are available for any photographs or illustrations appearing in this copy for an additional charge. Contact UMI directly to order. UMI ABell & Howell Information Company 300 North Zeeb Road, Ami Arbor MI 48106-1346 USA 3131761-4700 800/521-0600 -- --_._---------- THE IMPACT OF MAMMOGRAPHY UTILIZATION ON BREAST CANCER INCIDENCE IN HAWAII A DISSERTATION SUBMITTED TO THE GRADUATE DIVISION OF THE UNIVERSITY OF HAWAII IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY IN BIOMEDICAL SCIENCES (BIOSTATISTICS-EPIDEMIOLOGY) MAY 1996 By Gertraud Maskarinec Dissertation Committee: F. DeWolfe Miller, Chairperson John S. Grove Alan R. Katz Laurence N. Kolonel David M. Morens Joel M. Hanna UMI Number: 9629839 Copyright 1996 by Maskarinec, Gertraud All rights reserved. UMI Microfonn 9629839 Copyright 1996, by UMI Company. All rights reserved. This microfonn edition is protected against unauthorized copying under Title 17, United States Code. UMI 300 North Zeeb Road Ann Arbor, MI 48103 © Copyright 1996 by Gertraud Maskarinec All Rights Reserved iii Acknowledgments This project was supported by a research grant from the National Cancer Institute, Prevention and Control Branch, no. R03 CA63305. I am very grateful for the assistance of my graduate assistant at the Cancer Research Center of Hawaii, Ms. Lixin Meng, and for the support of Dr. Andy White, Hawaii Medical Service Association, and Mr. Darrell Kikuchi, Kaiser Permanente, who prepared the data sets. Many thanks go to Mrs. Lynne Wilkens at the Cancer Research Center of Hawaii for all her statistical advice, to my former co-workers at the Department of Health, Office of Health Status Monitoring, and to the staff of the Hawaii Tumor Registry. iv Abstract This research is an ecologic study investigating the association between mammography utilization and breast cancer incidence in Hawaii with the hypothesis that geographic areas with high mammography rates have higher breast cancer incidence rates than geographic areas with low mammography rates. Insurance claims for mammograms received during 1992/93 were combined with breast cancer incidence data from the state-wide Hawaii Tumor Registry, the 1990 Census ZIP File, and death records. Insurance claims data were obtained from four private and three public health plans and covered approximately 85% of the state's female population age 40 years old and older. Age-specific breast cancer incidence rates for each of the 79 ZIP code areas were regressed on mammography rates and selected demographic variables using both multiple linear and multiple logistic regression. An estimated 42% of women 40 years old and older had received at least one mammogram during the study period 1992 to 1993, with the highest rate (45%) in women 50 to 64 years old. Overall, 23% of the variation in age-specific breast cancer incidence was associated with mammography utilization, another 23% with age, and 4% with educational attainment. The relation between mammography use and breast cancer incidence was strongest for women 50 to 64 years old and weakest for women 40 to 49 years old. Mammography v utilization predicted 17% of the variance in localized disease, but very little of the variance of in situ or advanced disease. Neither mammography utilization nor demographic variables were found to be good predictors of geographic variations in breast cancer mortality in Hawaii. In summary, geographic areas in Hawaii with high mammography utilization experienced higher breast cancer incidence rates than areas with low mammography utilization. The size of this effect was consistent with the increase in breast cancer rates observed since the mid-eighties, supporting the hypothesis that the increase in breast cancer incidence is attributable to screening and early detection. However, the long term increase in breast cancer incidence requires alternate explanations. vi Table of Contents Acknowledgments iv Abstract v List of Tables ix List of Figures xii List of Abbreviations xiv Introduction ................................................... .. 1 Background and Literature Review 3 Etiology of Breast Cancer .................................. .. 3 Breast Cancer Incidence and Mortality 6 Mammography Screening as Early Detection Tool 9 Effect of Screening on Incidence Rates " 13 Mammography in Hawaii i 9 Insurance Claims Data in Epidemiologic Research 22 Ecologic Study Design 25 Materials and Methods ........................................... 31 Study Design 31 Study Population. 33 Data Sources 35 Insurance Claims " 35 Hawaii Tumor Registry 37 Census Data ........................................ 38 vii Mortality Data 40 Delta Processing ........................................... 41 Statistical Analysis 43 Results 48 Description of Insurance Claims 48 Mammography Utilization 48 Breast Cancer Incidence 53 Relation between Mammography Use and Breast Cancer Incidence " 55 Breast Cancer Mortality ..................................... 60 Discussion 63 Brief Summary of Findings ................................... 63 Limitations 65 Strengths 71 Alternate Explanations ...................................... 73 Interpretation of the Results 77 Conclusions 81 Appendix A- Tables 83 Appendix B- Figures 110 References ................................................. .. 136 viii List of Tables Table 1. Age-adjusted Breast Cancer Incidence Rates, Hawaii, 1960 - 1993 By Stage at Diagnosis (per 100,000 Women) 83 Table 2. Breast Cancer Incidence Attributable to Mammography Screening 52 Summary of Literature (Adapted from Newcomb and Lantz )••••• 84 Table 3. Participation in Mammography Screening By Age Group, BRFSS, Hawaii, 1990 - 1993 85 113 Table 4. Hawaii's Health Insurance Market, 1993 (adapted from HMSA ) •• 86 Table 5. Ethnic Distribution of Population in Hawaii, 1990 Comparison of Data from Census and HSP ................... 87 Table 6. Procedure Codes Used to Extract Mammography Claims Hawaii, 1992 - 1993 88 Table 7. Hawaii Post Office Box ZIP Codes with Geographic Assignment .. 89 Table 8. Data Sources for Mammography Claims, Hawaii, 1992 - 1993 .... 90 Table 9. Mammography Rates by County and Age Group By Year and Mammography Type, Hawaii, 1992 - 1993 91 Table 10. Univariate Statistics and Regression Coefficients for Demographic Variables, Hawaii, 1992 - 1993 ............................. 92 Table 11. Factors Related to Mammography Utilization, Hawaii, 1992 - 1993 Results of Multiple Linear Regression 93 Table 12. Breast Cancer Incidence by County and Age Group Hawaii, 1992 - 1993 94 Table 13. Demographic Variables Related to Breast Cancer Incidence Results of Multiple Linear Regression, Hawaii, 1992 - 1993 95 Table 14. Relation of Mammography Utilization and Breast Cancer Incidence Results of Simple Linear Regression, Hawaii, 1992 - 1993 Coefficients of Determination by Age and Stage at Diagnosis ..... 96 ix Table 15. Factors Related to Breast Cancer Incidence Results of Multiple Linear Regression, Hawaii, 1992 - 1993 All Ages and Stages ..................................... 97 Table 16. Factors Related to Breast Cancer Incidence Results of Multiple Linear Regression, Hawaii, 1992 - 1993 By Stage at Diagnosis, All Mammograms 98 Table 17. Factors Related to Breast Cancer Incidence Results of Multiple Linear Regression, Hawaii, 1992 - 1993 By Stage at Diagnosis, Screening Mammograms 99 Table 18. Factors Related to Breast Cancer Incidence Results of Multiple Linear Regression, Hawaii, 1992 - 1993 By Age Group, All Mammograms .......................... 100 Table 19. Factors Related to Breast Cancer Incidence Results of Multiple Linear Regression, Hawaii, 1992 - 1993 By Age Group, Screening Mammograms .................... 101 Table 20. Summary of Factors Related to Breast Cancer Incidence Results of Multiple Linear Regression, Hawaii, 1992 - 1993 Coefficients of Determination by Age and Stage at Diagnosis .... 102 Table 21. Factors Related to Breast Cancer Incidence Results of Simple and Multiple Logistic Regression Hawaii, 1992 - 1993 103 Table 22. Factors Related to Breast Cancer Incidence Results of Multiple Logistic Regression, Hawaii, 1992 - 1993 By Age Group, All Mammograms .......................... 104 Table 23. Factors Related to Breast Cancer Incidence Results of Multiple Logistic Regression, Hawaii, 1992 - 1993 By Stage at Diagnosis, All Mammograms
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