Transcript B2B Pop Health, April 6_2009, part 1_printing

Back to Basics, 2009
POPULATION HEALTH (1):
GENERAL OBJECTIVES
N Birkett, MD
Epidemiology & Community Medicine
Based on slides prepared by Dr. R. Spasoff
Other resources available on Individual & Population Health web site
April 6, 2009
1
THE PLAN
• We will follow MCC Objectives for
Qualifying Examination (in italics)
• Focus is on topics not well covered in the
Toronto Notes (UTMCCQE)
• Three sessions: General Objectives &
Infectious Diseases, Clinical Presentations,
Additional Topics
April 6, 2009
2
THE PLAN(2)
• First class
– mainly lectures
• Other classes
– About 1.5-2 hours of lectures
– Review MCQs for 60 minutes
• A 10 minute break about half-way through
• You can interrupt for questions, etc. if
things aren’t clear.
April 6, 2009
3
THE PLAN (3)
• Session 1 (April 6, 1300-1600)
– Diagnostic tests
• Sensitivity, specificity, validity, PPV
–
–
–
–
–
Health Promotion
Critical Appraisal (more on April 7)
Elements of Health Economics
Vital Statistics
Overview of Communicable Disease control,
epidemics, etc.
April 6, 2009
4
THE PLAN (4)
• Session 2 (April 4, 1300-1600)
– Clinical Presentations
•
•
•
•
•
•
•
Periodic Health Examination
Immunization
Occupational Health
Health of Special Populations
Disease Prevention
Determinants of Health
Environmental Health
April 6, 2009
5
THE PLAN (5)
• Session 3 (April 9, 1300-1600)
– CLEO
• Overview of Ethical Principles
• Organization of Health Care Delivery in Canada
– Other topics
• Intro to Biostatistics
• Brief overview of epidemiological research methods
April 6, 2009
6
LMCC New Objectives (1)
Population Health
• Concepts of Health and Its Determinants (78-1)
• Assessing and Measuring Health Status at the
Population Level (78-2)
• Interventions at the Population Level (78-3)
• Administration of Effective Health Programs at
the Population Level (78-4)
• Outbreak Management (78-5)
• Environment (78-6)
• Health of Special Populations (78-7)
April 6, 2009
7
LMCC New Objectives (2)
C2LEO (URL to LMCC objective page)
• Considerations for
– Cultural-Communication, Legal, Ethical and
Organizational Aspects of the Practice of
Medicine
April 6, 2009
8
LMCC New Objectives (3)
• We won’t be able to cover every objective
in detail.
• Sessions will be based around objectives,
with links identified as appropriate.
• Start with some overviews.
April 6, 2009
9
LMCC New Objectives (4)
78.1: CONCEPTS OF HEALTH AND ITS
DETERMINANTS
•
Define and discuss the concepts of health,
wellness, illness, disease and sickness.
•
Describe the determinants of health and how
they affect the health of a population and the
individuals it comprises.
•
Lifecourse/natural history
•
Illness behaviour
•
Culture and spirituality
April 6, 2009
10
LMCC New Objectives (5)
78.1: CONCEPTS OF HEALTH AND ITS DETERMINANTS
•
Determinants of health include:
–
–
–
–
–
–
–
–
–
–
–
–
Income/social status
Social support networks
Education/literacy
Employment/working conditions
Social environments
Physical environments
Personal health practices/coping skills
Healthy child development
Biology/genetic endowment
Health services
Gender
Culture
April 6, 2009
11
LMCC New Objectives (6)
78.2: ASSESSING AND MEASURING HEALTH
STATUS AT THE POPULATION LEVEL
•
Describe the health status of a defined
population.
•
Measure and record the factors that affect the
health status of a population with respect to the
principles of causation
– Principles of Epidemiology, critical appraisal,
causation, etc.
April 6, 2009
12
LMCC New Objectives (7)
78.3: INTERVENTIONS AT THE
POPULATION LEVEL
•
Understand three levels of prevention
•
Concepts of Health Promotion, etc.
•
Role of physicians at the community
level.
•
Impact of public policy
April 6, 2009
13
LMCC New Objectives (8)
78.4: ADMINISTRATION OF EFFECTIVE
HEALTH PROGRAMS AT THE
POPULATION LEVEL
•
Structure of the Canadian Health Care
System
•
Concepts of economic evaluation
•
Quality of care assessment
April 6, 2009
14
LMCC New Objectives (9)
78.5: OUTBREAK MANAGEMENT
•
Know defining characteristics of an
outbreak
•
Demonstrate essential skills in outbreak
control
April 6, 2009
15
LMCC New Objectives (10)
78.6: ENVIRONMENT
•
Recognize implications of environmental
health at the individual and community levels
•
Know methods of information gathering
•
Work collaboratively with other groups
•
Recommend to patients and groups how they
can minimize risk and maximize overall
function
April 6, 2009
16
LMCC New Objectives (11)
78.7: HEALTH OF SPECIAL POPULATIONS
•
Specific target population include:
–
–
–
–
–
First Nations, Inuit, Métis Peoples
Global health and immigration
Persons with disabilities
Homeless persons
Challenges at the extremes of the age continuum
April 6, 2009
17
LMCC New Objectives (12)
C2LEO
•
Same material as before but restructured.
•
Read objectives for the details
April 6, 2009
18
Getting Started
• We can’t cover everything.
• Will concentrate on topics not well covered in the
Toronto notes and material of greatest importance.
• Material will ‘jump around’ a bit
– Slides were based on previous LMCC objectives. I
didn’t get new objectives until the week before these
lectures. Hence, material won’t flow by LMCC
objectives but rather by content links.
April 6, 2009
19
INVESTIGATIONS (1)
• 78.2
– Determine the reliability and predictive value of
common investigations
– Applicable to both screening and diagnostic
tests.
April 6, 2009
20
Reliability
• = reproducibility. Does it produce the same
result every time?
• Related to chance error
• Averages out in the long run, but in patient
care you hope to do a test only once;
therefore, you need a reliable test
April 6, 2009
21
Validity
• Whether it measures what it purports to
measure in long run, viz., presence or
absence of disease
• Normally use criterion validity, comparing
test results to a gold standard
• Link to I&PH web on validity
April 6, 2009
22
Reliability and Validity: the metaphor of
target shooting. Here, reliability is represented by
consistency, and validity by aim
Reliability
Low
Low
•
•
•
Validity
High
•••
•••
•
•
•
•
High •
•
•
•
• April 6, 2009
•••
••
•
23
Gold Standards
• Possible gold standards:
– More definitive (but expensive or invasive) test
– Complete work-up
– Eventual outcome (for screening tests, when
workup of well patients is unethical; in clinical
care you cannot wait)
• First two depend upon current state of
knowledge and available technology
April 6, 2009
24
Test Properties (1)
Test +ve
Diseased
Not diseased
90
5
True positives
Test -ve
10
95
False positives
95
False negatives
100
True negatives
100
April 6, 2009
105
200
25
Test Properties (2)
Diseased
Not diseased
Test +ve
90
5
95
Test -ve
10
95
105
100
100
200
Sensitivity = 0.90
Specificity = 0.95
April 6, 2009
26
2x2 Table for Testing a Test
Test Positive
Test Negative
Gold standard
Disease Disease
Present
Absent
a (TP)
b (FP)
c (FN)
d (TN)
Sensitivity Specificity
= a/(a+c) = d/(b+d)
April 6, 2009
27
Test Properties (6)
• Sensitivity =
• Specificity =
Pr(test positive in a person
with disease)
Pr(test negative in a person
without disease)
• Range: 0 to 1
–
–
–
–
> 0.9:
0.8-0.9:
0.7-0.8:
< 0.7:
Excellent
Not bad
So-so
Poor
April 6, 2009
28
Test Properties (7)
• Values depend on cutoff point
• Generally, high sensitivity is associated with low
specificity and vice-versa.
• Not affected by prevalence, if severity is constant
• Do you want a test to have high sensitivity or high
specificity?
– Depends on cost of ‘false positive’ and ‘false negative’
cases
– PKU – one false negative is a disaster
– Ottawa Ankle Rules
April 6, 2009
29
Test Properties (8)
• Sens/Spec not directly useful to clinician,
who knows only the test result
• Patients don’t ask: if I’ve got the disease
how likely is it that the test will be positive?
• They ask: “My test is positive. Does that
mean I have the disease?”
• Predictive values.
April 6, 2009
30
Test Properties (9)
Diseased
Not diseased
Test +ve
90
5
95
Test -ve
10
95
105
100
100
200
April 6, 2009
PPV =
0.95
NPV =
0.90
31
2x2 Table for Testing a Test
Gold standard
Disease
Disease
Present
Absent
Test + a (TP) b (FP)
Test - c (FN) d (TN)
a+c
b+d
April 6, 2009
PPV = a/(a+b)
NPV= d/(c+d)
32
Predictive Values
• Based on rows, not columns
– PPV = a/(a+b); interprets positive test
– NPV = d/(c+d); interprets negative test
• Depend upon prevalence of disease, so must
be determined for each clinical setting
• Immediately useful to clinician: they
provide the probability that the patient has
the disease
April 6, 2009
33
Prevalence of Disease
• Is your best guess about the probability that
the patient has the disease, before you do
the test
• Also known as Pretest Probability of
Disease
• (a+c)/N in 2x2 table
• Is closely related to Pre-test odds of disease:
(a+c)/(b+d)
April 6, 2009
34
Test Properties (10)
Diseased
Not diseased
Test +ve
a
b
a+b
Test -ve
c
d
c+d
prevalence
a+c
b+d
a+b+c+d
=N
odds
April 6, 2009
35
Prevalence and Predictive Values
• Predictive values for a test dependent on the
pre-test prevalence of the disease
– Tertiary hospitals see more pathology then
FP’s; hence, their tests are more often true
positives.
• How to ‘calibrate’ a test for use in a
different setting?
• Relies on the stability of sensitivity &
specificity across populations.
April 6, 2009
36
Methods for Calibrating a Test
Four methods can be used:
–
–
–
–
Apply definitive test to a consecutive series of
patients (rarely feasible)
Hypothetical table
Bayes’s Theorem
Nomogram
You need to be able to do one of the last 3.
By far the easiest is using a hypothetical
table.
April 6, 2009
37
Calibration by hypothetical table
Fill cells in following order:
“Truth”
Disease Disease
Present
Absent
Test Pos
4th
7th
Test Neg
5th
6th
Total
2nd
3rd
April 6, 2009
Total
PV
8th 10th
9th 11th
1st (10,000)
38
Test Properties (12)
Tertiary care: research study. Prev=0.5
Test +ve
Diseased
Not diseased
425
50
475
PPV = 0.89
Test -ve
75
450
525
500
500
1,000
Sens = 0.85
Spec = 0.90
April 6, 2009
39
Test Properties (13)
Primary care: Prev=0.01
Diseased
Test +ve
Test -ve
Not diseased
85
0.85*100
990
15
8,910
0.9*9900
0.01*10000
100
9,900
April 6, 2009
1,075
PPV = 0.08
8,925
10,000
40
Calibration by Bayes’ Theorem
• You don’t need to learn Bayes’ theorem
• Instead, work with the Likelihood Ratio
(+ve).
April 6, 2009
41
Test Properties (9)
Diseased Not
diseased
90
5
95
Test
+ve
Test - 10
ve
100
95
105
100
200
Post-test odds =
18.0
Pre-test odds =
1.00
Likelihood ratio (+ve) = LR(+) = 18.0/1.0 = 18.0
April 6, 2009
42
Calibration by Bayes’s Theorem
• You can convert sens and spec to likelihood
ratios
– LR+ = sens/(1-spec)
• LR+ is fixed across populations just like
sensitivity & specificity.
• Bigger is better.
• Posttest odds = pretest odds * LR+
– Convert to posttest probability if desired…
April 6, 2009
43
Calibration by Bayes’s Theorem
• How does this help?
• Remember:
– Post-test odds = pretest odds * LR (+)
• To ‘calibrate’ your test for a new population:
–
–
–
–
Use the LR+ value from the reference source
Compute the pre-test odds for your population
Compute the post-test odds
Convert to post-test probability to get PPV
April 6, 2009
44
Converting odds to probabilities
• Pre-test odds = prevalence/(1-prevalence)
– if prevalence = 0.20, then pre-test odds =
.20/0.80 = 0.25
• Post-test probability =
post-test odds/(1+post-test odds)
– if post-test odds = 0.25, then prob = .25/1.25 =
0.2
April 6, 2009
45
Example of Bayes’s Theorem
(‘new’ prevalence 1%, sens 85%, spec 90%)
•
•
•
•
LR+ = .85/.1 = 8.5 (>1, but not that great)
Pretest odds = .01/.99 = 0.0101
Positive Posttest odds = .0101*8.5 = .0859
PPV = .0859/1.0859 = 0.079 = 7.9%
• Compare to the ‘hypothetical table’ method
(PPV=8%)
April 6, 2009
46
Calibration with Nomogram
• Graphical approach avoids some arithmetic
• Expresses prevalence and predictive values
as probabilities (no need to convert to odds)
• Draw lines from pretest probability
(=prevalence) through likelihood ratios;
extend to estimate posttest probabilities
• Only useful if someone gives you the
nomogram!
April 6, 2009
47
Example of Nomogram
(pretest probability 1%, LR+ 45, LR– 0.102)
1%
45
31%
.102
0.1%
Pretest Prob.
LR
April 6, 2009
Posttest Prob.
48
INVESTIGATIONS (2)
State the effect of demographic considerations on the
sensitivity and specificity of diagnostic tests
• Generally, assumed to be constant. BUT…..
• Sensitivity and specificity usually vary with
severity of disease, and may vary with age and sex
• Therefore, you can use sensitivity and specificity
only if they were determined on patients similar to
your own
• Spectrum bias
April 6, 2009
49
The Government is extremely fond of amassing
great quantities of statistics. These are raised to
the nth degree, the cube roots are extracted, and
the results are arranged into elaborate and
impressive displays. What must be kept ever in
mind, however, is that in every case, the figures are
first put down by a village watchman, and he puts
down anything he damn well pleases!
Sir Josiah Stamp,
Her Majesty’s Collector of Internal Revenue.
April 6, 2009
50
78.3: HEALTH PROMOTION &
MAINTENANCE (1)
• Definitions of health
• Concepts of Health Promotion
April 6, 2009
51
Definitions of Health
1.
A state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity.
[The WHO, 1948]
2.
A joyful attitude toward life and a cheerful acceptance of
the responsibility that life puts upon the individual
[Sigerist, 1941]
3.
The ability to identify and to realize aspirations, to
satisfy needs, and to change or cope with the
environment. Health is therefore a resource for everyday
life, not the objective of living. Health is a positive
concept emphasizing social and personal resources, as
well as physical capacities. (WHO Europe, 1986]
April 6, 2009
52
HEALTH PROMOTION
• Distinct from disease prevention.
• Focuses on ‘health’ rather than ‘illness’
• Broad perspective. Concerns a network of
issues, not a single pathology.
• Participatory approach. Requires active
community involvement.
• Partnerships with NGO’s, NPO’s, etc.
April 6, 2009
53
HEALTH PROMOTION
• Ottawa Charter for Health Promotion
(1996)
• Five key pillars to action:
–
–
–
–
–
Build Healthy Public Policy
Create supportive environments
Strengthen community action
Develop personal skills
Re-orient health services
April 6, 2009
54
HEALTH PROMOTION
• Health Education
– Health Belief model
– Stages of Change model
• Risk reduction strategies
• Social Marketing
• Healthy public policy
– Tax policy to promote healthy behaviour
– Anti-smoking laws, seatbelt laws
– Affordable housing
April 6, 2009
55
78.1: Illness Behaviour
• “Describe the concept of illness behaviour
and its influence on health care”
• Utilization of curative services, coping
mechanisms, change in daily activities
• Patients may seek care early or may delay
(avoidance, denial)
• Adherence may increase or decrease
April 6, 2009
56
April 6, 2009
57
April 6, 2009
58
April 6, 2009
59
78.2: CRITICAL APPRAISAL (1)
• “Evaluate scientific literature in order to
critically assess the benefits and risks of
current and proposed methods of
investigation, treatment and prevention of
illness”
• Most will be covered in session on April 9
• UTMCCQE does not present hierarchy of
evidence (e.g., as used by Task Force on
Preventive Health Services)
April 6, 2009
60
Hierarchy of evidence
(lowest to highest quality, approximately)
•
•
•
•
•
•
•
•
•
Expert opinion
Case report/series
Ecological (for individual-level exposures)
Cross-sectional
Case-Control
Historical Cohort
Prospective Cohort
Quasi-experimental similar/identical
Experimental (Randomized)
}
April 6, 2009
61
78.1: MEDICAL ECONOMICS (1)
• Define the socio-economic rationales,
implications and consequences of medical
care
• Medical care costs society financial and
other resources.
• This objective aims to raise awareness of
these types of issues.
April 6, 2009
62
MEDICAL ECONOMICS (2)
• Is there a net financial benefit from medical
care?
• How do we value non-fiscal benefits such
as quality of life, ‘health’, not being dead?
• Should resources be spent on health or other
societal objectives?
• How do we value non-traditional
expenditures, etc which impact on health
(Healthy Public Policy).
April 6, 2009
63
MEDICAL ECONOMICS (3)
• “Outline the principles of cost-containment,
cost benefit analysis and cost effectiveness”
• Not addressed in UTMCCQE
April 6, 2009
64
Principles of cost-containment
• Eliminate ineffective care
• Reduce costs of effective care
– Substitute cheaper but equally effective care,
• day surgery for hospital admission,
• nurse practitioners for some primary care,
• generic drugs
– Reduce unit costs
• reduce salaries (risk of reduced effectiveness) or
fees (but quantity provided may increase)
April 6, 2009
65
Types of economic analysis
[Costs always expressed in dollars]
• Cost-minimization: assume equal outcomes
• Cost-benefit: outcomes in dollars
• *Cost-effectiveness: outcomes in natural
units (deaths, days of care or disability, etc.)
• *Cost-utility: outcomes in QALYs (qualityadjusted life years)
April 6, 2009
66
78.1: VITAL STATISTICS
INFORMATION
• What are the key causes of illness or death
in Canada? Common things are common –
using epidemiology can help you run a
better clinical practice
• How have disease incidence and mortality
change in Canada in the past 20 years?
– Little good information on disease incidence
except for cancer (cancer registries)
April 6, 2009
67
# deaths in Canada from 1979-2004; men and women.
13/7/2008
April 6, 2009
68 68
Mortality RATES in Canada from 1979-2004; men and women.
13/7/2008
April 6, 2009
69 69
VITAL STATISTICS (2)
• Leading causes of death
– ‘Cardiovascular disease’: 37%
• Heart disease: 20%
• ‘Other circulatory disease’: 10%
• ‘Stroke’ 7%
– ‘Cancer’: 28%
• Lung cancer: 9% (M); 6% (W)
• Breast cancer: 4% (W)
• Prostate cancer: 4% (M)
–
–
–
–
Respiratory Disease: 10%
Injuries: 6%
Diabetes: 3%
Alzheimer’s: 1%
April 6, 2009
70
Mortality (2004) - Canada, both sexes
Age standardized: 1991 population
Cancer: Lung (8.1%)
CHD:other (5.4%)
Cancer: Colon (3.3%)
Cancer: Breast (2.2%)
CANCER:
30.3%
IHD (16.1%)
Circ
Disease:
27.6%
Cancer: Other (16.7%)
Stroke (6.1%)
Accidents:MVA (1.5%)
Other (21.8%)
Accidents:Other (2.8%)
Diabetes (3.5%)
Infections (1.2%)
††
† Respiratory (6.7%)
Suicide (1.9%)
Alzheimer's (2.2%)
† Pneumonia & influenza
Aprilgrouped
6, 2009 with respiratory disease.
Would increase infectious % to about 3.4%.
71
Mortality (2004) - Canada, MEN only
Age standardized: 1991 population
Cancer: Lung (8.5%)
CHD:other (4.9%)
Cancer: Colon (3.3%)
Cancer: Prostate (3.3%)
IHD (18.8%)
CANCER:
29.8%
Circ
Disease:
29.0%
Cancer: Other (14.7%)
Stroke (5.3%)
Accidents:MVA (1.8%)
Other (20.8%)
Accidents:Other (3.0%)
Diabetes (3.5%)
†Infections (1.1%)
†
Respiratory (7.2%)
Suicide (2.3%)
Alzheimer's (1.5%)
† Pneumonia & influenza
Aprilgrouped
6, 2009 with respiratory disease.
Would increase infectious % to about 3.5%.
72
Mortality (2004) - Canada, WOMEN only
Age standardized: 1991 population
Cancer: Lung (7.8%)
CHD:other (5.8%)
Cancer: Colon (3.2%)
Cancer: Breast (5.0%)
IHD (14.5%)
CANCER:
31.6%
Circ
Disease:
27.3%
Cancer: Other (15.6%)
Stroke (7.0%)
Accidents:MVA (1.0%)
Accidents:Other (2.4%)
Other (22.7%)
Diabetes (3.4%)
Infections (1.0%)
†
†
Respiratory (6.5%)
Suicide (1.1%) Alzheimer's (2.9%)
† Pneumonia & influenza
Aprilgrouped
6, 2009 with respiratory disease.
Would increase infectious % to about 3.3%.
73
Sex ratio (M/F) in Canada from 1979-2004.
April 6, 2009
74
Age/sex-specific Mortality.
Canada, 2005
14000
Combined
Males
Females
12000
Rate/100,000
10000
8000
6000
4000
2000
0
0
20
40
60
80
Age at death (years)
April 6, 2009
75
Age-specific mortality: male:female mortality ratio
Canada, 2005
1.0=same mortality in both sexes; > 1.0 -> higher male mortality
2.8
2.6
2.4
Ratio (M:F)
2.2
2.0
1.8
1.6
1.4
1.2
1.0
0
20
40
60
80
Age (years)
April 6, 2009
76
PYLL’s for various conditions, 2001
April 6, 2009
77
Injury Mortality in Canada, 2004
350
Total
MVA
Falls
Suffocation
Other unintentional
Suicide
Homicide
300
Rate/100,000
250
200
150
100
50
0
0
20
40
60
80
Age at death (years)
April 6, 2009
78
Injury Mortality in Canada, 2004
Excluding poeple over age 80
70
Total
MVA
Falls
Suffocation
Other unintentional
Suicide
Homicide
60
Rate/100,000
50
40
30
20
10
0
0
20
40
60
80
Age at death (years)
April 6, 2009
79
Pattern of Injury deaths, Canada, 2004
Age 1 to 10.
MVA
Falls
Suffocation
Other unintentional
Homicide
April 6, 2009
80
Pattern of Injury deaths, Canada, 2004
Age 80 and over.
MVA
Falls
Suffocation
Other unintentional
Suicide
Homicde
April 6, 2009
81
Vital Stats (3)
• In the USA, it is estimated that 86,000
people are sent to ER every year after a fall
caused by a cat or dog!
– Mainly minor injuries but 10% are fractures,
internal bleeding, etc.
– Cats mainly trip people by walking under your
feet.
– Dogs (the main source of injuries!) causes trips,
push people over or pull them over on walks.
• Watch out!!
April 6, 2009
82
April 6, 2009
83
Overall trends in mortality from Cancer 1976-2005:
rates and numbers
April 6, 2009
84
Overall trends in mortality 1976-2005: rates and numbers
April 6, 2009
85
Cancer and Age
Age-Specific Incidence Rates for All Cancers by Sex, Canada, 2003
April 6, 2009
Surveillance Division, CCDPC, Public Health Agency of Canada
86
Cancer and Age
Age-Specific Mortality Rates for All Cancers by Sex, Canada, 2003
April 6, 2009
Surveillance Division, CCDPC, Public Health Agency of Canada
87
Time trends in incidence - Males
160
Estimated
140
Prostate
120
Lung
100
80
Colorectal
60
40
Bladder
Stomach
NHL
20
Melanoma
0
1975
Larynx
Liver
Thyroid
1980
1985
1990
1995
2000
2005
Age-Standardized Incidence Rates (ASIR) for Selected
April 6, Cancer
2009 Sites, Males, Canada, 1978-2007
Surveillance and Risk Assessment Division, CCDPC, Public Health Agency of Canada
88
Time trends in mortality - Males
100
Estimated
Lung
80
ASMR (/100,000)
60
40
Colorectal
Prostate
20
Stomach
NHL
Oral
Larynx
Hodgkin's
0
1980
1985
1990
1995
2000
2005
Age-Standardized Incidence Rates (ASIR) for Selected
April 6, Cancer
2009 Sites, Males, Canada, 1978-2007
Surveillance and Risk Assessment Division, CCDPC, Public Health Agency of Canada
89
Time trends in incidence - Females
160
Estimated
140
120
100
Breast
80
60
Colorectal
40
Lung
20
Thyroid
Stomach
NHL
Cervix
Larynx
0
1975
1980
1985
1990
1995
2000
2005
Age-Standardized Incidence Rates (ASIR) for Selected
April 6, Cancer
2009 Sites, Females, Canada, 1978-2007 90
Surveillance and Risk Assessment Division, CCDPC, Public Health Agency of Canada
Time trends in mortality - Females
100
Estimated
80
ASMR (/100,000)
60
40
Lung
Breast
Colorectal
20
Stomach
NHL
Cervix
0
1980
1985
1990
1995
2000
2005
Age-Standardized Incidence Rates (ASIR) for Selected
April 6, Cancer
2009 Sites, females, Canada, 1978-2007 91
Surveillance and Risk Assessment Division, CCDPC, Public Health Agency of Canada