Affiliations of authors:S. S. Devesa, D. J. Grauman, J. F. Fraumeni, Jr., Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD; W. J. Blot, International Epidemiology Institute, Ltd., Rockville, MD.
Correspondence to: Susan S. Devesa, Ph.D., National Institutes of Health, Executive Plaza South, Rm. 8048, Bethesda, MD 20892 (e-mail: devesas{at}exchange.nih.gov).
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ABSTRACT |
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INTRODUCTION |
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MATERIALS AND METHODS |
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Age-adjusted (direct method, 1970 U.S. population standard) mortality rates per 100 000 person-years were calculated for the time periods from 1950 through 1959, from 1960 through 1969, from 1970 through 1979, from 1980 through 1989, and from 1990 through 1994 among whites and from 1970 through 1979, from 1980 through 1989, and from 1990 through 1994 among blacks (13). To allow comparison of the rates of change by considering the slopes of the lines, figures presenting the trends by the Census Division were prepared by use of a log scale for the y-axis. The y-axis-to-x-axis ratio of one log cycle to 40 years was used uniformly in all figures; this results in an annual change in rate of 1% to be portrayed by a line with a slope of 10 degrees (14). Prior to preparing the maps, we deemed rates for an SEA on the basis of sparse data to be unstable if (a) the observed number of deaths was fewer than six;(b)the observed number of deaths was fewer than 12 and the rate was not significantly different statistically from the national rate; or (c) the expected number of deaths was fewer than six and the rate was not significantly different statistically from the U.S. rate. For each race, sex, and time period, the stable SEA-level rates were ranked and partitioned into deciles, and maps were prepared with color codes that used shades of red and blue. Areas with rates based on sparse numbers of deaths were shaded gray.
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RESULTS |
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Geographic variation in lung cancer mortality was pronounced in nearly all time periods.
During the period from 1950 through 1959, rates among white males were elevated in urban
areas
of the northeast and along the south Atlantic and Gulf coasts (Fig. 2, A).
Over time, however, the northeast excesses became less evident, as rates rose more rapidly in
other areas of the country (Fig. 2
, B-E). By the 1970s, many of the
highest rates occurred in the southeast quadrant of the country, with broader coastal bands of
high rates spreading inland and also along the Mississippi Valley. By the 1990s, virtually all of
the rates in the highest decile occurred in the southeast quadrant. In contrast, rates in the North
Central and Mountain areas remained low relative to the rest of the country, while rates in the
northeast and far west approximated the national rate.
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DISCUSSION |
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We present maps for which the rates have been ranked independently for each combination of race, sex, and time period. An alternative would be to combine the rates across time periodsand even, perhaps, across race or sex categoriesbefore ranking and partitioning into deciles. However, because of the substantial increases in rates over time, this approach would result in mostly blue maps for early years and red maps for more recent years. Because of the much higher rates among males than among females, combining the data for both sexes would result in mostly red maps for males and blue maps for females. Maps combining the data for both races would be difficult to interpret because of the large areas with sparse data for blacks. The approach that we chose avoids these problems and enables clearer assessment of the geographic contrasts within each map.
Only limited data are available according to SEA on risk factors that have been associated
with the distribution of lung cancer. Because cigarette smoking is the dominant cause of lung
cancer in the United States (15), we evaluated data from previous
population surveys of smoking rates by area of residence. Although indicators of cigarette
consumption at the state level, based on sales tax data, have been available for many years (16), the earliest sex- and state-specific data we could find pertained to
1985, although even these data were not race specific (17). Fig. 6,
A (males) and B (females), plots the distribution of
current smokers in 1985 by state (17). Among white males, the patterns
of smoking prevalence and lung cancer rates for 1990 through 1994 appear to be similar, with
high-rate areas for both variables in the southeastern quadrant of the country. Among females,
the concordance was less pronounced. Because estimates of the prevalence of smoking are
weighted toward young and middle-aged adults and the mortality rates are dominated by deaths
at generally older ages, the 1985 smoking patterns for both males and females may predict lung
cancer mortality rates in the decades to come. Formal statistical evaluation of the potential
associations between the SEA-specific lung cancer mortality rates and the state-specific
prevalences of smoking is beyond the scope of this analysis.
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Among females in the 1950s, the prevalence of current smokers was highest in the West and lowest in the South (19). By the 1980s, however, white women in the West, in both the Pacific and the Mountain states, had the lowest percentage of current smokers among all regions (21). Thus, the lung cancer patterns among white women, particularly the Pacific coastal excess, are consistent with the high smoking rates in earlier years, but the recent shifts in smoking prevalence are not yet reflected in the lung cancer patterns. Among black females, however, the 1985 prevalence of smoking was highest in the North Central region and lowest in the South, thus resembling the distribution of lung cancer.
Although smoking patterns largely account for the regional variation in lung cancer mortality, the early maps (1,3) and subsequent correlation studies also suggested a relation to certain occupational exposures (23,24) and prompted a series of case-control studies in high-risk areas, particularly along the southern seaboard. In the 1970s and early 1980s, studies in coastal Georgia (25), Tidewater Virginia (26), northeast Florida (27), and southern Louisiana (28) revealed an excess risk of lung cancer associated with work in shipyards, primarily during World War II. Asbestos exposure appeared to be the major hazard, especially since clusters of mesothelioma were also observed in certain coastal areas (29,30). In the more recent maps, the coastal excess of lung cancer among men was less pronounced, perhaps because of a diminished effect of wartime asbestos exposures in shipyards, since risk of lung cancer is known to decline following cessation of asbestos exposure (18). Indeed, a case-control study of lung cancer in northeast Florida during the 1990s found no significant excess risk associated with prior work in shipyards (31). It is possible that the recent clustering of high lung cancer rates among females in coastal areas may be partly related to asbestos exposures associated with the shipbuilding industry in view of synergistic effects with smoking, although few women worked in the industry and the high rates extended to coastal areas without shipyards.
Correlation studies have also revealed elevated rates of lung cancer among males and females residing in counties with arsenic-emitting smelters (32), prompting case-control studies raising the possibility that there are carcinogenic effects of neighborhood as well as occupational exposure to inorganic arsenic (33). Further epidemiologic studies in high-risk areas should continue to generate insights into occupational and other environmental determinants of lung cancer.
The geographic patterns of lung cancer may also be useful in targeting health planning and prevention programs. Lung cancer has become the second leading cause of death (following heart disease) among U.S. men and the third leading cause of death (following heart and cerebrovascular diseases) among U.S. women (34), thus accounting for hundreds of thousands of premature deaths. The changing patterns of smoking prevalence and subsequent lung cancer rates should help identify target populations where anti-tobacco research and control programs are especially needed to reduce the enormous toll of this preventable disease. In particular, the study of high-risk populations affords a special opportunity for behavioral studies to understand the determinants of smoking and to develop the most effective measures aimed at smoking cessation.
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NOTES |
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APPENDIX. Census divisions and states |
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Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont
Middle Atlantic
New Jersey, New York, and Pennsylvania
South Atlantic
Delaware, District of Columbia, Florida, Georgia, Maryland, North Carolina, South Carolina, Virginia, and West Virginia
East North Central
Illinois, Indiana, Michigan, Ohio, and Wisconsin
East South Central
Alabama, Kentucky, Mississippi, and Tennessee
West North Central
Iowa, Kansas, Missouri, Minnesota, Nebraska, North Dakota, and South Dakota
West South Central
Arkansas, Louisiana, Oklahoma, and Texas
Mountain
Arizona, Colorado, Idaho, Montana, Nevada, New Mexico, Utah, and Wyoming
Pacific
Alaska, California, Hawaii, Oregon, and Washington
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REFERENCES |
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Manuscript received January 12, 1999; revised March 5, 1999; accepted April 26, 1999.
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