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When all cancers are taken into consideration, breast cancer has the highest rate of occurrence in women in the United States (see figure 1). These rates have been true since the mid-1950s. Only recently has lung cancer surpassed breast cancer in mortality rate in the United States [1]. However, women in Utah still have a higher mortality rate due to breast cancer, rather than lung cancer [2], most likely due to Utah’s low rate of smoking tobacco. Utah is ranked the fifth lowest state for deaths due to invasive breast cancer [5]. Utah’s breast cancer incidence and mortality rates have remained relatively stable over the past decade (see Figure 2).

A recently published study concluded that breast cancer incidence rates have dropped by approximately 7% from 2002 to 2003. This decrease is the largest decline seen in over a decade. The study offered the decline of hormone replacement therapy in post-menopausal women as the major contributing factor. The decline in incidence rate of breast cancer was even higher among women aged 50 and older; their rate dropped by 15% during the same time period. Hormone replacement therapy usage has dropped approximately 30% since the Women’s Health Initiative study, published in 2002, concluded that hormone replacement therapy increased women’s risk of developing breast cancer, among a plethora of other health problems [3].

In the United States, mortality rates due to breast cancer have decreased by an average of 2.3% per year from 1990-2002 [1]. This reduction is most likely due to increased screening mammograms and detection of breast cancer at an earlier stage in the disease process. Women in the U.S. have a 12.67% lifetime risk of developing breast cancer [4]. Lifetime risk assessments refer to the risk of developing a disease during one’s lifetime.

When race and ethnicity are considered, white women have the highest incidence rate of breast cancer when age groups are pooled. Black women have significantly higher incidence rates of breast cancer before age 40 compared to white women. After age 50, black women have a significantly lower incidence rate when compared with white women. Black women are more likely to be diagnosed with breast cancer at a more advanced stage of disease than white women and, therefore, are more likely to die from breast cancer. These differences are likely due to disparities in insurance coverage and socioeconomic status. American Indian women and Asian/ Pacific Islander women have lower incidence rates of breast cancer than white women. Hispanic women have a lower incidence rate of breast cancer than non-Hispanic women [6].

Known risk factors for breast cancer include, family history, genetics (BRCA1 and 2 which account for approximately 5-10% of breast cancer cases), long menstrual time (early menstrual start or late menopause), obesity, hormone replacement therapy, oral contraceptive use, never having children, and having a first birth after age thirty [1].

Mammography is the first line for early detection. The American Cancer Society recommends that women aged 40 and older receive mammograms every one to two years. Once women are 50 and older, annual mammograms are recommended. Younger women should perform self-examinations monthly and get regular examinations by a health care provider. Maintaining a healthy body weight, breast feeding, and maintaining an active lifestyle may help to reduce the risk of developing breast cancer [1].

References

1. American Cancer Society. Available Online at http://www.cancer.org. Retrieved on Sep 24, 2006.
2. Utah’s Indicator-Based Information System for Public Health: Breast Cancer Incidence, Breast Cancer Mortality, Breast Cancer Screening Outcomes. Available Online at http://ibis.health.utah.gov. Retrieved on Oct 11, 2006.
3. MD Anderson. Available Online at http://www.mdanderson.org. Retrieved on Dec 15, 2006.
4. Center for Disease Control. Available Online at http://cdc.wonder.org. Retrieved on Sep 24, 2006.
5. National Cancer Institute. Available Online at http://cancer.gov. Retrieved on Oct 13, 2006.
6. Joslyn, SA; Foote, ML; Nasseri, K; Coughlin, SS; Howe, HL. (2005). Racial and ethnic disparities in breast cancer rates by age. NAACCR Breast Cancer Project. Breast Cancer Research and Treatment, 92(2): 97-105.

Since the advent of the Pap test, cervical deaths have steadily decreased since 1955, and are still continuing to decrease today [1]. The Pap test can detect abnormal cells in the cervix including precancerous lesions that may develop into invasive cancer. Today, the American Cancer Society estimates that less than 10,000 cases of invasive cervical cancer will occur in the United States in 2006 [1].

Hispanic women in the U.S. have markedly higher cervical cancer rates than their non-Hispanic white counterparts. Some estimates of cervical cancer rates in Hispanic women are nearly twice the rate of non-Hispanic white women. Women of African-American heritage experience cervical cancer at almost a 50% higher rate than white women of non-Hispanic descent [2].

Utah’s cervical cancer rates are lower than the collective United States rate. From 1994-2003, Utah women averaged an incidence rate of 6.8 per 100,000 person-years versus the United State’s average of 9.3 per 100,000 person-years [2]. When this rate is broken down into racial/ethnic groups, our state’s differences mirror the national statistics fairly closely, with Hispanic women suffering the greatest proportion of the disease burden. See figures 1 and 2 for details. Survival rates for invasive cervical cancer are very promising, ranging from 92% 5-year survival rates for detection at the earliest stage, to 73% 5-year survival rate for all stages of detection combined [1,3].

Risk factors for cervical cancer can be categorized into alterable factors and unchangeable factors. Alterable factors include unsafe sexual behaviors that lead to infection of human papillomavirus (HPV), smoking, obesity, physical inactivity, and vegetable and fruit deficient diets. Unchangeable factors include family history of cervical cancer, older age, and having already been infected with a cancer-causing strain of HPV [1,3].

Recently the FDA approved the vaccine Gardasil which has been shown to prevent four types of HPV infections, namely strains 6, 11, 16, and 18. Strains 6 and 11 cause about 90% of genital warts, while strains 16 and 18 cause around 70% of cervical cancers [3]. This vaccine is recommended for girls aged 9-11, before they become sexually active. It is recommended that females up to the age of 26 receive a “catch up” vaccine. It has not been shown to be cost-effective in women over the age of 30 [2]. Once a woman has been infected with HPV there is no cure for the infection. However, many women who become infected with HPV are able to clear the infection with no lingering effects, showing that merely being infected with HPV does not mean that cancer will develop. There is disparate information in the literature as to whether all cervical cancers are caused by an HPV infection (as the American Cancer Society states) or whether just most of cervical cancers are caused by HPV (as the National Cancer Institute states).

Regular Pap tests and vaccination are the two best ways to prevent the development of cervical cancer. The frequency of testing and ages at which testing should begin and end should be discussed with your physician. Living a safe and healthy lifestyle including practicing safe sex, maintaining a healthy weight, physical activity, eating at least five fruits and vegetables daily, and not smoking are all ways that may help prevent cervical cancer [1].

References

1. American Cancer Society. Available Online at http://www.cancer.org. Retrieved on Dec 24, 2006.
2. Surveillance, Epidemiology and End Results (SEER) by the National Cancer Institute http://seer.cancer.gov/fstats. Retrieved Jan 7, 2007.
3. National Cancer Institute. Available Online at http://www.cancer.gov. Retrieved on Nov 27, 2006.
4. Utah’s Indicator-Based Information System for Public Health: Available Online at http://ibis.health.utah.gov. Retrieved on Dec 21, 2006.

Excluding skin cancer, colorectal cancer is the third most commonly diagnosed cancer in females in the United Stated and second most common in Utah. Cancer of the colon and rectum are very closely related and have many features in common. For this reason, researchers simply refer to them collectively as colorectal cancer. Death from colorectal cancer has decreased over the past decade. This reduction is largely attributed to increased screening procedures called colonoscopies that detect colorectal cancer at an early stage. It is quite common for doctors to find polyps, which are benign or non-cancerous tumors. These polyps, if left in the colon, can develop into colon cancer. Screening colonoscopies allow physicians to remove these polyps before they become malignant or cancerous [1].

If colorectal cancer is detected before it has spread to other areas of the body, 5-year survival rates are greater than 90%. However, less than 40% of colorectal cancers are discovered at this early stage. Once the cancer has spread to the other areas of the body, (metastatic colorectal cancer), 5-year survival rates are less than 10% [1].

Some risk factors for colorectal cancer cannot be changed. These risk factors include being over the age of 50, family history of colorectal cancer, having a history of colorectal polyps, chronic inflammatory bowel disease such as Crohn’s disease and ulcerative colitis, and genetic mutations. (Inflammatory bowel disease is quite different from the more common irritable bowel syndrome which does not increase risk of colorectal cancer). Other risk factors for colorectal cancer can be changed by altering behavior and improving lifestyle patterns. These risk factors include obesity, high fat and high animal-source diets, physical inactivity, smoking, and heavy alcohol use [1].

Researchers have been studying genetic mutations in colorectal cancer. They have recently identified nearly 200 mutated genes that are linked to cancer by tumor initiation, tumor growth, cancer spread, and cancer control [2]. Only about 20% to 30% of people with colorectal cancer have a family history of the disease and only 5% to 10% of those with a family history have an inherited genetic susceptibility [1,3].

Researchers at the University of Utah recently discovered a molecule that is associated with some colorectal cancers. By genetically disabling this molecule called adenomatous polyposis coli (APC) in zebrafish, researchers were able to protect them from the effects of genetic mutation [4].

Many times colorectal cancer has very ambiguous symptoms or no symptoms at all. For this reason, it is recommended that all people over the age of 50 see a physician for a complete physical exam, including a digital rectal exam, stool testing for occult bleeding, and colonoscopy or flexible sigmoidoscopy. Screening colonoscopies are usually recommended every 3-5 years. People at higher risk for developing colorectal cancer such as genetic mutations, family history, or other colorectal conditions may need to be screened at an earlier age than the general population [1,3].

Insurance coverage seems to play a sizable role in whether people get screened for colorectal cancer. Due to the cost of screening colonoscopies, those who do not have health insurance coverage do not usually get screened. In Utah residents aged 50 years and older, those with health insurance are twice as likely to get screening colonoscopies as those without health insurance [5].

Demographics also seem to play a role in whether Utah residents get screening colonoscopies. Those individuals living in non-urban areas (considered either rural or frontier) average 2% to 15% less likelihood for screening colonoscopies in the past five years than their urban counterparts [5].

Racial/ethnic disparities exist in both incidence and mortality rates of colon cancer victims. Black women have higher incidence and mortality rates of colorectal cancer than any other racial/ethnic group of females in the United States while Hispanic women have the lowest incidence and mortality rates. However, in Utah, Hispanic women have the second highest rate of colorectal cancer, following black women. See figures 2 and 3 for details [6].

References

1. American Cancer Society. Available Online at http://www.cancer.org. Retrieved on Dec 24, 2006.
2. Johns Hopkins Kimmel Cancer Center. Available Online at http://www.hopkinskimmelcancercenter.org. Retrieved on Jan 7, 2007.
3. MedicineNet, Inc. owned and operated by WebMD. Available Online at http://medicinenet.com. Retrieved on Jan 7, 2007.
4. University of Utah Huntsman Cancer Institute, News Center. Available Online at http://unews.utah.edu. Retrieved on Jan 7, 2007.
5. Utah Cancer Registry. Available Online at http://uuhsc.utah.edu/ucr/statistics&pubs.html.
6. Surveillance, Epidemiology and End Results (SEER) by the National Cancer Institute. Retrieved Jan 7, 2007 http://seer.cancer.gov/fstats
7. Utah’s Indicator-Based Information System for Public Health: Available Online at http://ibis.health.utah.gov. Retrieved on Oct 11, 2006.

Endometrial cancer refers to cancer that originates in the uterus (also called uterine cancer). Anywhere from 90% to 95% of endometrial cancers begin in the glandular cells of the uterus and are referred to as adenocarcinomas. The remaining five to ten percent of endometrial cancers arise outside of the glandular cells. These cancers include uterine sarcomas, stromal sarcomas, malignant mixed mesodermal tumors, and leiomyosarcomas [1,2]. The information regarding risk factors and survival rates sited in this document refer to adenocarcinomas only. However, the statistics on incidence and mortality both at the state and national level (shown in figures 1, 2, and 3) refer to all types of uterine cancers. These divergences were impractical to remedy due differing data collection and reporting practices between organizations.

Lifetime risk of being diagnosed with endometrial cancer is about 1 in 38 (less than 3%). The 5-year survival rates vary depending on stage of diagnosis but when averaged together, 5-year survival is about 84% [1]. Utah’s overall endometrial cancer incidence rate is slightly lower than the national rate (23.5 per 100,000 person-years vs. 24.3 per 100,000 person-years). When broken down into racial/ethnic categories, disparities exist between groups. White women experience a higher rate of endometrial cancer compared to black women, however, black women are more likely to die from endometrial cancer than white women. Women of Hispanic, American- Indian, Alaskan, Asian, and Pacific Island heritage experience lower rates of endometrial cancer than white and black women [3]. Asian/Pacific Islanders in Utah do not follow this national pattern perfectly having the second highest rates of endometrial cancer. See figure 1 for details.

Risk factors for endometrial cancer include early menarche (before age 12), late menopause (after age 52), never having children and having very few children, obesity, family history of endometrial cancer, diabetes, gall bladder disease, high blood pressure, and a diet high in animal fats. Other risk factors include ovarian disease such as polycystic ovarian syndrome, ovarian cancer, breast cancer, endometrial hyperplasia, pelvic radiation therapy, estrogen replacement therapy, and tamoxifen use [1,2].

Endometrial cancer usually occurs after menopause and does not occur very often in younger women. Abnormal vaginal bleeding is the most common symptom associated with endometrial cancer but does always mean a woman has cancer. Often times there are no symptoms of the disease [2].

References

1. American Cancer Society. Available Online at http://www.cancer.org. Retrieved on Dec 24, 2006.
2. United States Department of Health and Human Services, Women’s Health Division. Available Online at http://www.womenshealth.gov. Retrieved on Nov 3, 2006.
3. Surveillance, Epidemiology and End Results (SEER) by the National Cancer Institute http://seer.cancer.gov/fstats. Retrieved Jan 7, 2007.
4. Utah’s Indicator-Based Information System for Public Health: Available Online at http://ibis.health.utah.gov. Retrieved on Dec 21, 2006.

Lung cancer has the highest mortality rate of all cancers in the U.S.. It accounts for more deaths per year than breast, prostate, and colorectal cancers combined [1]. In all states, overall cancer rates are declining, however, lung cancer rates in American women are still on the rise. Experts believe the incline may be reaching a plateau over the last two years due to a decrease in smoking rates [2]. Utah’s lung cancer rates (both incidence and mortality rates) are significantly lower than the national average. In 2002, Utah’s incidence and mortality rates were less than half that of the United States. These lower rates are almost certainly due to our state population’s lower smoking rates. From 1998 to 2002, Utah was ranked lower than any other state in incidence and mortality rates due to lung cancer (See figure 1) [2].

Nearly 80,000 women are estimated to die of lung cancer this year in the United States. For reasons still unclear to researchers, women are at an increased risk of developing lung cancer than men when exposed to the same levels of tobacco smoke over time. This increased risk is especially true in low-level exposure to cigarettes [2]. Although survival rates have improved over the last three decades, lung cancer still has a relatively poor prognosis. On average only about 15% of patients diagnosed with lung cancer survive for five years after diagnosis [2].

Cigarette smoking is the most significant risk factor for developing lung cancer. Between 85% to 95% of all lung cancer cases are attributed to smoking [1]. Other risk factors include environmental and/or occupational exposures such as asbestos and radon. Secondhand smoke poses a significant risk in the development of lung cancer as well, especially when a person is exposed during childhood. There has also been evidence to show that genetics play a role in the risk of developing lung cancer [2,3,4].

Unfortunately, there are no early detection tests that have been shown effective in improving mortality rates in lung cancer. In 2002, the National Cancer Institute began a clinical trial to determine if CT scans can detect lung cancer at an earlier stage and in turn, decrease mortality rates [3].

An important aspect of lung cancer is the stigma that comes with the diagnosis. Since most lung cancer victims are smokers, many people feel that lung cancer is a self-inflicted and, therefore, a deserved disease. This social stigma leads to lung cancer victims feeling guilt and shame which in turn leads to a decreased desire to see a physician for treatment [2]. Non-smokers find it difficult to understand the powerful addiction of cigarettes. Many experts believe that this stigma has been a major influence leading to a severe lack of research funds to tackle the problem of lung cancer. Although lung cancer kills more Americans than any other cancer, funding for research is among the lowest for any cancer (See figure 2) [2].

References

1. Available Online at http://lungcancer.org. Retrieved on Oct 23, 2006.
2. American Cancer Society. Available Online at http://www.cancer.org. Retrieved on Sep 24, 2006.
3. National Cancer Institute. Available Online at http://cancer.gov. Retrieved on Oct 13, 2006.
4. Center for Disease Control. Available Online at http://cdc.wonder.org. Retrieved on Sep 24, 2006.
5. Utah’s Indicator-Based Information System for Public Health: Breast Cancer Incidence, Breast Cancer Mortality, Breast Cancer Screening Outcomes. Available Online at http://ibis.health.utah.gov. Retrieved on Oct 11, 2006.

Ovarian cancer is the eighth most common cancer in females in the United States, excluding non-melanoma skin cancer. It accounts for approximately 20,000 deaths per year nationally. In Utah, ovarian cancer rates are approximately the same as national rates. However, Utah’s death rates due to ovarian cancer were approximately 1% lower than the national mortality rate (8.2% vs. 9%) [1]. Lifetime risk of developing ovarian cancer is 1.5%. Upon diagnosis of ovarian cancer, less than half (about 45%) of women will survive longer than five years. However, if the ovarian cancer is detected early and has not spread to the surrounding tissue, 5-year survival rates are approximately 94%. Unfortunately, only about one in every five cases of ovarian cancer is detected at an early stage. Ovarian cancer incidence rates have decreased by about 0.7% per year since 1985 [2]. In Utah, ovarian cancer incidence and mortality rates have remained approximately stable from 1993 to 2005 [1].

Risk factors for ovarian cancer include family history, being over age 55, never having children, and menopausal hormone replacement therapy. Family history of ovarian cancer means having a mother, daughter, or sister with ovarian cancer. Links have been made between breast, uterine, colorectal, melanoma, thyroid, and pancreas cancers. Genetic mutations such as BRCA1 and BRCA2 are sometimes seen in women with ovarian cancer. White women have higher incidence rates and mortality rates of ovarian cancer compared to black women (See figure 2) [3].

A new study published in December 2006 showed a decrease of ovarian cancer in women who live in sunnier regions of the world. Researchers attributed this to vitamin D production which occurs in the body when exposed to sunlight. Researchers caution that people should not over expose themselves to sunlight as skin cancer is a far more common disease than ovarian cancer. Researchers state that people with fair skin need less than 15 minutes per day with less than 50% of their skin exposed for the maximum benefit. Studies are being done to assess whether vitamin D supplements are as effective as naturally occurring vitamin D made in the body [4].

There are no screening tests proven to be effective for early diagnosis of ovarian cancer. The signs and symptoms of ovarian cancer can be ambiguous and difficult to distinguish from benign conditions. Symptoms may include abdominal bloating, pelvic pain, vaginal bleeding, back or leg pain, and intestinal discomforts and abnormalities [3]. Annual gynecological exams by a physician are recommended because doctors are sometimes able to feel abnormalities in the ovaries and other reproductive organs. It is sometimes very difficult to detect abnormalities because the organs are deep within the pelvis and not easily palpable. Studies are being conducted by the National Cancer Institute to evaluate possible screening methods that may help to diagnose this cancer early and decrease mortality rates [2].

References

1. Utah Department of Health. Available online at http://ibis.health.utah.gov. Accessed Oct 11, 2006.
2. National Cancer Institute. Available online at http://www.cancer.gov. Accessed Dec 7, 2006.
3. American Cancer Society. Available online at http://www.cancer.org. Accessed on Nov 20, 2006.
4. American Journal of Preventive Medicine, December 2006. Abstract available online at Reuters Health at http://reutershealth.org. Accessed on Nov 20, 2006.

Background

Breast cancer is the most commonly occurring cancer in U.S. women (excluding basal and squamous cell skin cancers) and the leading cause of female cancer death in Utah. Deaths from breast cancer can be substantially reduced if the tumor is discovered at an early stage. Clinical trials have demonstrated that routine screening with mammography can reduce breast cancer deaths by 20% to 30% in women aged 50 to 69 years, and by about 17% in women aged 40 to 49 years. Recent research suggests that ultrasound may be a better screening tool for some women. Pap smears are another screening that is recommended for women.

Healthy People 2010 Objective 3.13:
Mammograms – Adults receiving within past 2 years (age adjusted, females aged 40 years and older), U.S. Target for 2010: 70%, Utah Target for 2010: 80% in 2010

Healthy People 2010 Objective 3.11b:
Pap test – Women aged 18 years and older who received a Pap test within the preceding 3 years, U.S. Target for 2010: 90%

Risk Factors

The most important risk factor for breast cancer is increasing age. Other established risk factors include personal or family history of breast cancer, history of abnormal breast biopsy, early age at onset of menses, late age at onset of menopause, never having children or having a first live birth at age 30 or older. Associations have also been suggested between breast cancer and oral contraceptives, long-term use of hormone replacement therapy, obesity (in post-menopausal women), alcohol, and a diet high in fat. The American Cancer Society recommends that women aged 40 or older have an annual mammogram, while the National Cancer Institute, the U.S. Preventive Services Task Force, and the U.S. Department of Health and Human Services recommend that women 40 years or older undergo mammography every 1-2 years. Women who are at higher than average risk of breast cancer should seek expert medical advice about whether they should begin screening before age 40 and the frequency of that screening. It is recommended that women over age 21 get a Pap test and pelvic exam every 1 to 3 years.

Utah data vs. U.S.- How are we doing

Services/Hotlines

The Utah Cancer Control Program (UCCP) provides free to low cost clinical breast exams and mammograms to women who meet age and income guidelines. Eligible women with abnormal screening exams are offered diagnostic evaluation by participating providers. In addition, the UCCP provides education about the need for early detection and the availability of screening services, performs outreach to eligible women, uses an annual reminder system, collects outcome data and disseminates information about breast cancer. As of July 1, 2001, the UCCP is able to refer Utah women in need of treatment for breast and cervical cancers and precancerous lesions for full Medicaid benefits. The women must meet all requirements as outlined in the National Breast and Cervical Cancer Treatment Act.

References

1. Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System Survey Data. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, custom query accessed 1/9/07
2. Behavioral Risk Factor Surveillance System, Retrieved on 1/9/07 from Utah Department of Health, Center for Health Data, Indicator-Based Information System for Public Health. Website: http://ibis.health.utah.gov/