Ovarian cancer incidence in the United States, 1992-1999

OBJECTIVE: The purpose of this epidemiological study was to report histology-specific age-adjusted ovarian cancer incidence rates that were standardized to the recently adopted year 2000 United States standard population. METHODS: We utilized data gathered from eleven population-based cancer registries of the Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute for the years 1992 through 1999. Our analyses included data on 23,484 microscopically confirmed cases of primary malignant ovarian cancer that were diagnosed in women residing in the eleven SEER registries. RESULTS: We categorized the 117 different histologies that were diagnosed in the 23,484 ovarian cancer cases into ten major classifications. The overall age-adjusted incidence rate for all ovarian cancer cases was 16.23 cases per 100,000 women. Epithelial tumors displayed the highest age-adjusted incidence rate (15.48), followed by germ cell tumors (0.41), sex cord-stromal tumors (0.20), and all other miscellaneous ovarian tumors (0.13). Serous epithelial tumors were the most commonly observed epithelial group (6.77 cases per 100,000 women), followed by other miscellaneous epithelial tumors (3.76), mucinous epithelial tumors (2.22), endometrioid epithelial tumors (2.11), and clear cell epithelial tumors (0.64). Notable differences were observed in the age-adjusted incidence rates for White and Black women. CONCLUSIONS: Age-adjusted incidence rates of ovarian cancer vary by histology. This is the first study to standardize histology-specific age-adjusted incidence rates of ovarian cancer to the new 2000 United States standard population.     

Cervical cancer screening practices of certified nurse-midwives in the United States

The purpose of this study was to determine how closely certified nurse-midwives in the United States follow contemporary cervical cancer screening guidelines. A survey was sent to 264 randomly selected certified nurse-midwives. Survey questions included demographics and clinical scenarios addressing initiation, frequency, and cessation of screening. Responses were received from 60% of the sampled certified nurse-midwives who had valid mailing addresses; 127 were eligible for the analytic sample. Many nurse-midwives initiate cervical cancer screening earlier than guidelines recommend; 72% would initiate screening in an 18-year-old within 1 month of coitarche, while 36% would begin screening virginal girls at age 18, and many continue cervical cancer screening after guidelines recommend cessation. More than 60% of the respondents would continue screening a woman who had undergone total hysterectomy for symptomatic fibroids who had no history of dysplasia, and half would continue to screen a 70-year-old woman with a 30-year history of previous normal Pap tests. In addition, despite guidelines which recommend less frequent screening, more than one-quarter (28%) would continue annual screening in a 35-year-old woman with three or more normal tests. Certified nurse-midwives are performing cervical cancer screening more frequently than current guidelines recommend. Comparisons to the practice of other providers are offered. Education to limit unnecessary testing is needed.     

Cervical cancer screening, abnormal cytology management, and counseling practices in the United States

OBJECTIVE: We assessed clinician knowledge and practices since the marketing of tests for sexually transmitted human papillomavirus (HPV) and the release of HPV testing guidelines for two indications: 1) as an adjunct to cytologic screening and 2) to guide colposcopic triage of patients with atypical squamous cells of undetermined significance (ASC-US) cytology results. METHODS: In mid-2004, we surveyed nationally representative, random samples of clinicians practicing specialties that provide cytologic screening. Mail surveys addressed HPV-related knowledge, screening, abnormal cytology management, HPV testing, and counseling practices. RESULTS: The overall adjusted response rate was 82%. Of the 2,980 (89%) clinicians providing cytologic screening, 99% knew that HPV infection increases cervical cancer risk, and 91% were aware of HPV tests. Of the 21% who reported ever using HPV tests as an adjunct to cytology, more reported usually testing patients aged less than 30 years (which guidelines do not recommend) than older patients (which guidelines do recommend). Of the 63% of clinicians who ever ordered HPV tests for abnormal cytology results, 84% usually ordered tests for ASC-US results and preferentially advised colposcopy if HPV tests were positive, as guidelines recommend. However, more than 60% usually ordered HPV tests for higher-grade abnormalities, which is not recommended for colposcopy triage. Although few sought HPV test consent, most discussed sexually transmitted HPV with patients with abnormal cytology or positive HPV tests despite potentially negative psychosocial consequences. CONCLUSION: New HPV tests and testing guidelines have transformed screening, abnormal cytology management, and counseling practices. Although many U.S. clinicians reported using HPV tests according to guidelines, many also reported inappropriate use.     

Pregnancy-related substance use in the United States during 1996-1998

OBJECTIVE: To provide a baseline estimate of the national prevalence of pregnancy-related illicit drug use and abstinence rates. METHODS: We analyzed data collected between 1996 and 1998 from the National Household Survey on Drug Abuse, a nationally representative sample survey of 22,303 noninstitutionalized women aged 18-44 years, of whom 1,249 were pregnant. RESULTS: During 1996-1998, 6.4% of nonpregnant women of childbearing age and 2.8% of pregnant women reported that they used illicit drugs. Of the women who used drugs, the relative proportion of women who abstained from illicit drugs after recognition of pregnancy increased from 28% during the first trimester of pregnancy to 93% by the third trimester. However, because of postpregnancy relapse, the net pregnancy-related reduction in illicit drug use at postpartum was only 24%. Marijuana accounted for three-fourths of illicit drug use, and cocaine accounted for one-tenth of illicit drug use. Of those who used illicit drugs, over half of pregnant and two-thirds of nonpregnant women also used cigarettes and alcohol. Among the sociodemographic subgroups, pregnant and nonpregnant women who were young (18-30 years) or unmarried, and pregnant women with less than high school education had the highest rates of illicit drug use. CONCLUSION: The continued burden of illicit drug use during pregnancy calls for policy efforts to enable primary care providers to identify and refer women who use substances to treatment and support services. Prevention of uptake of illicit drug use should be an integral part of public health programs for young women.     

Down syndrome births in the United States from 1989 to 2001

OBJECTIVE: We investigated the observed and expected Down syndrome livebirths in the US from 1989 to 2001. STUDY DESIGN: Using birth certificate data, we recorded maternal age-specific live births from 1989 to 2001, and stratified them by women 15 to 34 and 35 to 49 years old. We estimated Down syndrome live births from 1989 to 2001, assuming no terminations. We recorded Down syndrome live births by year from 1989 to 2001. RESULTS: Despite an expected 1.32-fold increase in Down syndrome live birth rates from 1989 to 2001, Down syndrome live births actually declined. In 1989, the rate of Down syndrome cases was 15% lower than expected, decreasing to 51% by 1998. Women 15 to 34 had 45% fewer affected pregnancies in 2001, while women 35 to 49 had 53% fewer in 2001. We estimated that Down syndrome live births decreased from 3962 in 1989 to 3654 in 2001. CONCLUSION: Down syndrome live births declined in the US despite an expected increase caused by delayed or extended childbearing.     

Untreated cervical cancer in the United States

OBJECTIVE: To evaluate treatment patterns, including lack of treatment, among women diagnosed with cervical cancer in the United States. METHODS: Using the National Cancer Institute's (NCI's) Surveillance, Epidemiology, and End Results (SEER) program, we identified 13,715 women diagnosed with invasive cervical cancer between 1992 and 1999 and eligible for inclusion in the study. RESULTS: Nearly 9% of women diagnosed with invasive cervical cancer received no therapy for their disease. Lack of therapy was associated with a later stage of disease at diagnosis, older age, and unmarried status. More than 16% of women aged 65 and older with stage IIB/IV cervical cancer received no therapy for their disease. CONCLUSION: We must educate women diagnosed with cervical cancer and their families about the importance of treatment for potential cure and control of symptoms. We must identify and overcome obstacles that may prevent adherence to treatment recommendations. These may include comorbidity, access to cancer treatment, inability to pay for treatment, and inadequate social support.     

Trends in fetal growth among singleton gestations in the United States and Canada, 1985 through 1998

We examined trends in fetal growth among singleton live births in the United States and Canada. The data files (n = 48,637,680; 16.6% blacks) for US births, and the Canadian Birth Database of Statistics Canada (n = 3,167,702) for Canadian births were used. Trends were assessed between 1985-86 and 1997-98 with reference to mean birthweight, birthweight-for-gestational-age z-score, and proportions delivered low birthweight (< 2,500 g), small for gestational age (SGA: birthweight < 10th centile for gestational age) and large for gestational age (LGA: birthweight > 90th centile). The term "mean birth weight" increased in the US and Canada between 1985 and 1998, as have the mean z-score. Rates of term SGA births declined among US (11% among whites and 12% among blacks) and Canadian births (27%). Preterm SGA births increased by 3% and 17%, respectively, among US whites and blacks, but declined by 11% among Canadian births. Further, term LGA births increased in the US (5% among whites and 9% among blacks) and Canada (24%). Preterm LGA births declined by 13%, 25%, and 14% among US whites and blacks, and Canadian births, respectively. These findings suggest that US and Canadian babies are getting bigger. The role of preterm obstetrical induction and preterm cesarean delivery are likely to have influenced these trends.     

Placental abruption in the United States, 1979 through 2001: temporal trends and potential determinants

OBJECTIVE: The purpose of this study was to evaluate temporal trends in abruption risk and to assess how much underlying changes in the clinical determinants may have affected these trends. STUDY DESIGN: We used the National Hospital Discharge Summary data (1979-2001), an annual survey of sampled non-federal, short stay, general, and specialty hospitals in the United States. Trends in abruption were assessed for the periods 1979 through 1981 and 1999 through 2001. Clinical determinants of abruption that were evaluated included hypertensive diseases, anemia, gestational diabetes mellitus, preterm labor, preterm premature rupture of membranes, chorioamnionitis, oligohydramnios, obstetric shock/trauma, uterine tumors, short umbilical cord, and velamentous cord insertion. Temporal trends in abruption were examined before and after adjustment for determinants through multivariable logistic regression. RESULTS: The rate of abruption increased 92% (95% CI, 88, 96) among black women between 1979-1981 (0.76%; n = 13,584 women) and 1999-2001 (1.43%; n = 18,960 women). Among white women, the rate increased by 15% (95% CI, 14,16) over the same period, from 0.82% (n = 66,186 women) in 1979-1981 to 0.94% (n = 59,284 women) in 1999-2001. The determinants that were associated with trends in abruption included anemia, gestational diabetes mellitus, preterm labor, short umbilical cord, and velamentous cord insertion, although their effects varied substantially by maternal race. CONCLUSION: The temporal increase in rates of abruption may reflect a true increase in risk or may be the result of improved diagnosis of both abruption and its determinants. Although the cause of abruption is still speculative, the trend is of concern and deserves scrutiny.     

Trends in the Use of Episiotomy in the United States: 1980–1998

Background: Despite a relative paucity of clinical evidence justifying its routine use, approximately 40 percent of all vaginal deliveries include an episiotomy. The purpose of this study is to examine trends in episiotomy in the United States from 1980 through 1998, a period during which calls increased to abandon routine episiotomy. Methods: Data were obtained from the National Hospital Discharge Survey, which is conducted annually and based on a nationally representative sample of discharges from short‐stay non‐Federal hospitals. Results: From 1980 through 1998 the episiotomy rate in the United States dropped by 39 percent. Rates decreased for all age and racial groups investigated, in all four geographic regions, and for all sources of payment. Significant differences remained between groups in 1998, including a higher rate for white women than for black women, and a higher rate for women with private insurance than for women with Medicaid or in the self‐pay category. The incidence of first‐ and second‐degree lacerations to the perineum increased for women without episiotomies, but the more severe third‐ and fourth‐degree lacerations remained more frequent for women with episiotomies. Women with episiotomies were more likely to have forceps‐assisted deliveries or vacuum extractions. Conclusions: Despite dramatic declines in the use of episiotomy during the last two decades, it remains one of the most frequent surgical procedures performed on women in the United States, and it continues to be performed at a higher rate for certain groups of women.     

Sudden infant death syndrome among twin births: United States, 1995-1998.

OBJECTIVES: To compare the incidence and risk factors for sudden infant death syndrome (SIDS) in twin and singleton births and to estimate the concordance of SIDS in twins. STUDY DESIGN: A cohort analysis using the National Center for Health Statistics Linked Birth and Infant Death files (1995-1998). RESULTS: Twins had higher SIDS rate (1.3/1000 live births) compared to singletons (0.7/1000 live births), relative risk: 1.9, 95% confidence interval: 1.68, 2.01. Male and small- for-gestational age infants as well as infants of black, unmarried, and smoking mothers were at increased risk for SIDS in both twins and singletons. Placental abnormalities also were associated with SIDS in singletons and twins, although this association failed to achieve statistical significance in twins. There is a higher rate of SIDS in the second twin after a first twin SIDS. CONCLUSIONS: Twins are at higher risk of SIDS than are singletons. Overall, the epidemiology of SIDS in twins is quite similar to that seen in singletons.