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									                                                                               CANCER INCIDENCE IN THE U.S. AIR FORCE: 1989—2002
                                                                                                                                 Grover K. Yamane, MD, MPH
                                                                                                                                      Col, USAF, MC, SFS
                                                                                                  Epidemiology Services Branch, Air Force Institute for Operational Health, Brooks City-Base, TX



                                               INTRODUCTION                                                                                                             RESULTS                                                                                                                                                                    CONCLUSIONS

Cancer is one of the most significant causes of morbidity and mortality in the U.S. While not a formal geo-             -- Cancer cases.                                                                                                  -- The cancer experience of the AFAD population differed substantially from that of the U.S. general population.
political or cultural entity, the military services comprise a large, well-defined population. Due to its sheer size,       -- There were a total of 2,750 incident cases of invasive cancer among 2,714 AFAD personnel: 1,986 cases      -- Fundamental differences between the AFAD and U.S. general populations could have accounted for these
cancer has the potential to be a substantial public health burden for the U.S. military as well.                            in 1,959 males, and 764 cases in 755 females.                                                                 findings.
                                                                                                                            -- A few personnel had more than 1 incident cancer type: 24 (1.3%) males and 9 (1.2%) females.                -- The USAF Medical Service may need to consider the unique features of the AFAD population cancer
Yet, cancer incidence in the general active duty force has been little studied. To our knowledge, no study has              -- For all personnel, the mean age was 35.1 yr (SD: 8.7 yr); median age, 35 yr; and age range, 17-60 yr.      experience in constructing its cancer programs.
attempted to describe the general cancer experience of the U.S. Air Force (USAF). As with the civilian sector,                  -- For males, the mean age was 35.8 yr (SD: 8.6 yr); median age, 36 yr; and age range, 17-60 yr.
characterizing the frequency and distribution of cancer may ultimately allow for more effective planning of
cancer prevention, screening, treatment, patient support, professional education, and research efforts.                         -- For females, the mean age was 33.2 yr (SD: 8.5 yr); median age, 33 yr; and age range, 18-57 yr.                                                     Table 1. Standardized Incidence Ratios for the 10 Most Frequent Invasive Cancers in U.S. Air Force Active Duty Personnel: 1989-2002

                                                                                                                        -- Cancer incidence.                                                                                                  Rank                                  Cancer Type                                   Cases
                                                                                                                                                                                                                                                                                                                                             Expected Number of
                                                                                                                                                                                                                                                                                                                                                    Cases
                                                                                                                                                                                                                                                                                                                                                                               Standardized
                                                                                                                                                                                                                                                                                                                                                                              Incidence Ratio             95% CI            Mean Age (yrs)       Age SD          Median Age (yrs)             Age Range (yrs)
                                                                                                                            -- The SIR for all cancer types (adjusted for age, gender, and race) was 0.58 (95% CI: 0.56-0.60).
                                            STUDY QUESTIONS                                                                     -- For males, the SIR for all cancer types (adjusted for age and race) was 0.50 (95% CI: 0.48-0.53).
                                                                                                                                                                                                                                           Males
                                                                                                                                                                                                                                           1             Cutaneous Malignant Melanoma                                               406               379.62                         1.07                0.97-1.18               36.6                 7.5                 37                        18-58
                                                                                                                                                                                                                                           2             Testicular Germ Cell Carcinoma                                             354               520.07                         0.68                0.61-0.76               30.8                 6.5                 30                        18-51
                                                                                                                                                                                                                                           3             Prostate Adenocarcinoma                                                    142                98.76                         1.44                1.21-1.69               47.7                 5.6                 48                        33-60
                                                                                                                                -- For females, the SIR for all cancer types (adjusted for age and race) was 0.96 (95% CI: 0.89-1.03).     4             Non-Hodgkin Lymphoma                                                       136               432.96                         0.31                0.26-0.37               35.3                 8.0                 36                        20-58
-- What is the incidence of invasive cancer in the U.S. Air Force active duty (AFAD) population, compared to            -- Cancer types.
                                                                                                                                                                                                                                           5             Thyroid Follicular and/or Papillary Carcinoma                              121               116.27                         1.04                0.86-1.24               34.5                 8.1                 35                        21-59
                                                                                                                                                                                                                                           6             Hodgkin's Disease                                                          116               217.47                         0.53                0.44-0.64               31.2                 7.6                 32                        18-52
that in the U.S. general population?                                                                                                                                                                                                       7             Colorectal Adenocarcinoma                                                  107               205.62                         0.52                0.43-0.63               39.5                 7.2                 40                        21-59
                                                                                                                            -- Table 1 gives the 10 most frequent cancer types for males and females and their respective SIRs. These      8             Brain Neuroepithelial Carcinoma                                            70                159.11                         0.44                0.34-0.56               30.9                 7.5                 30                        18-54
-- What are the most common invasive cancer types in the AFAD population?                                                   accounted for 77.6% and 88.1% of all incident invasive cancers in males and females, respectively. Table 2     9 (tie)       Urinary Bladder Transitional Cell Carcinoma                                45                 98.27                         0.46                0.33-0.61               40.1                 8.2                 40                        19-55
                                                                                                                                                                                                                                           9 (tie)       Oral Squamous Cell Carcinoma                                               45                 86.67                         0.52                0.38-0.69               37.9                 6.9                 38                        24-53
                                                                                                                            compares the 10 most frequent cancer types in the U.S. general and AFAD populations.                           Females
                                                   METHODS                                                                                                                                                                                 1
                                                                                                                                                                                                                                           2
                                                                                                                                                                                                                                                         Breast Adenocarcinoma
                                                                                                                                                                                                                                                         Cervical Carcinoma
                                                                                                                                                                                                                                                                                                                                    204
                                                                                                                                                                                                                                                                                                                                    180
                                                                                                                                                                                                                                                                                                                                                      232.31
                                                                                                                                                                                                                                                                                                                                                       56.36
                                                                                                                                                                                                                                                                                                                                                                                     0.88
                                                                                                                                                                                                                                                                                                                                                                                     3.19
                                                                                                                                                                                                                                                                                                                                                                                                         0.76-1.01
                                                                                                                                                                                                                                                                                                                                                                                                         2.74-3.70
                                                                                                                                                                                                                                                                                                                                                                                                                                 39.8
                                                                                                                                                                                                                                                                                                                                                                                                                                 28.4
                                                                                                                                                                                                                                                                                                                                                                                                                                                      5.9
                                                                                                                                                                                                                                                                                                                                                                                                                                                      6.8
                                                                                                                                                                                                                                                                                                                                                                                                                                                                          41
                                                                                                                                                                                                                                                                                                                                                                                                                                                                          27
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    24-55
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    19-54
                                                                                                                                                                                                                                           3             Thyroid Follicular and/or Papillary Carcinoma                              95                 85.02                         1.12                0.90-1.37               30.5                 6.8                 29                        20-46
                                                                                                                                                                      DISCUSSION                                                           4             Cutaneous Malignant Melanoma                                               82                 79.49                         1.03                0.82-1.28               32.0                 7.3                 31                        19-49
                                                                                                                                                                                                                                           5             Hodgkin's Disease                                                          32                 39.76                         0.80                0.55-1.13               25.0                 5.5                 24                        18-44
-- Subjects.                                                                                                                                                                                                                               6             Colorectal Adenocarcinoma                                                  19                 25.57                         0.74                0.45-1.16               38.6                 7.3                 40                        22-48
                                                                                                                                                                                                                                           7 (tie)       Non-Hodgkin Lymphoma                                                       16                 31.54                         0.51                0.29-0.82               33.1                 8.2                 34                        19-45
    -- We obtained subjects with incident invasive cancer from the Automated Central Tumor Registry (ACTUR)             -- This study demonstrated the most frequently observed invasive cancers in the AFAD population differed from      7 (tie)       Ovarian Epithelial Carcinoma                                               16                 17.54                         0.91                0.52-1.47               34.6                 7.7                 36                        22-47
                                                                                                                                                                                                                                           9             Vulvar Carcinoma                                                           11                 3.10                          3.54                1.77-6.28               26.9                 9.0                 23                        19-46
    at the Armed Forces Institute of Pathology, Washington, DC. The ACTUR was established in 1986 to serve              those in the U.S. general population, both in incidence and composition.                                           10 (tie)      Brain Neuroepithelial Carcinoma                                             9                 19.41                         0.46                0.21-0.87               27.8                 9.1                 26                        18-42
    as the Department of Defense’s main cancer data collection, clinical tracking, and reporting system. Like           -- Certain factors associated with USAF military service might have affected the incidence of invasive cancer.
                                                                                                                                                                                                                                           10 (tie)      Oral Squamous Cell Carcinoma                                                9                 4.32                          2.08                0.95-3.91               40.0                 5.4                 41                        32-47

    other major registries, the ACTUR does not collect cutaneous basal cell and squamous cell cancer cases.                 -- Service regulations.
                                                                                                                                                                                                                                           1. Standardized incidence ratios in bold and underlined type were statistically significant.
                                                                                                                                                                                                                                           2. Reference invasive cancer incidence rates were obtained from the Surveillance, Surveillance, Epidemiology, and End Results 9 Database, National Cancer Institute, Bethesda, MD.
    -- Subjects were restricted to personnel who were on active duty in the USAF as of the date of incident                     -- USAF regulations specify disqualifying medical conditions, set maximum limits on body weight, and
                                                                                                                                                                                                                                           3. Excludes cutaneous basal cell and squamous cell cancers.

    cancer diagnosis. The study period was 1 January 1989 to 31 December 2002, inclusive. Although the                          require physical fitness. These might have reduced the prevalence of certain cancer risk factors.                                                    Table 2. Comparison of the 10 Most Frequent Incident Cancer Types in the U.S. General and U.S. Air Force Active Duty Populations
    ACTUR was established in 1986, we set the start of the study period to 1989, to allow for this program to
    develop, deploy, and expand throughout the military medical services.                                                   -- Selection bias.                                                                                                Rank                           U.S. General Population                                Proportion of All Cancers                         Rank                  U.S. Air Force Active Duty Population                           Proportion of All Cancers


    -- We determined cancer types using the subjects’ International Classification of Diseases for Oncology                     -- Self-selection for military duty may have yielded fewer persons with certain cancer-promoting           Males
                                                                                                                                                                                                                                           1            Prostate Cancer                                                                           33%                              1              Cutaneous Malignant Melanoma                                                          20.4%
    (ICDO)-1, ICDO-2, or ICDO-3 topology and morphology codes.                                                                  behaviors choosing to enter or continue service.                                                           2            Lung and Bronchus Cancer                                                                  13%                              2              Testicular Germ Cell Carcinoma                                                        17.8%
                                                                                                                                                                                                                                           3            Colon and Rectal Cancer                                                                   10%                              3              Prostate Adenocarcinoma                                                               7.2%
    -- Subjects’ Social Security Numbers were cross-checked against archival USAF military personnel                        -- Behaviors.                                                                                                  4            Urinary Bladder Cancer                                                                    7%                               4              Non-Hodgkin Lymphoma                                                                  6.8%
                                                                                                                                                                                                                                           5            Cutaneous Malignant Melanoma                                                              5%                               5              Thyroid Follicular and/or Papillary Carcinoma                                         6.1%
    databases maintained by the Air Force Personnel Center, Randolph AFB, TX, to confirm active duty status.                    -- The prevalence of certain cancer risk-modifying behaviors may have changed during service.              6            Non-Hodgkin Lymphoma                                                                      4%                               6              Hodgkin's Disease                                                                     5.8%
                                                                                                                                                                                                                                           7            Kidney and Renal Pelvis Cancer                                                            3%                               7              Colorectal Adenocarcinoma                                                             5.4%
-- AFAD population counts.                                                                                                  -- Healthcare access.                                                                                          8            Leukemia                                                                                  3%                               8              Brain Neuroepithelial Carcinoma                                                       3.5%
                                                                                                                                                                                                                                           9            Oral Cavity and Pharyngeal Cancer                                                         3%                               9 (tie)        Urinary Bladder Transitional Cell Carcinoma                                           2.3%
    -- We obtained AFAD population counts from the Defense Manpower Data Center, Seaside, CA. This                              -- High levels of healthcare access may have affected the development or detection of certain cancers.     10           Pancreatic Cancer                                                                         2%                               9 (tie)        Oral Squamous Cell Carcinoma                                                          2.3%
                                                                                                                                                                                                                                                        Total                                                                                     83%                                             Total                                                                                 77.6%
    Department of Defense agency collects a wide range of personnel data for all 4 military services.                       -- Table 3 gives the possible impacts of these factors on the most frequently observed cancer types.
                                                                                                                                                                                                                                           Females
-- Incidence reference rates.                                                                                           -- These findings may be useful in guiding cancer programs for the AFAD population.                                1            Breast Cancer                                                                             32%                              1              Breast Adenocarcinoma                                                                 26.7%
                                                                                                                                                                                                                                           2            Lung and Bronchus Cancer                                                                  12%                              2              Cervical Carcinoma (Invasive)                                                         23.6%
    -- We obtained invasive cancer incidence reference rates from the Surveillance, Epidemiology, and End                   -- Screening.                                                                                                  3            Colon and Rectal Cancer                                                                   11%                              3              Thyroid Follicular and/or Papillary Carcinoma                                         12.4%
                                                                                                                                                                                                                                           4            Uterine Corpus Cancer                                                                     6%                               4              Cutaneous Malignant Melanoma                                                          10.7%
    Results (SEER) Program at the National Cancer Institute, Bethesda, MD. The program’s SEER 9 database                        -- Decisions on implementing cancer screening programs may need to be made cautiously, since               5            Non-Hodgkin Lymphoma                                                                      4%                               5              Hodgkin's Disease                                                                     4.2%
                                                                                                                                                                                                                                           6            Cutaneous Malignant Melanoma                                                              4%                               6              Colorectal Adenocarcinoma                                                             2.5%
    was used. Cutaneous basal cell and squamous cell cancers are not included in this registry.                                 screening recommendations are based on average incidence populations. For several cancer types, the        7            Ovarian Cancer                                                                            3%                               7 (tie)        Non-Hodgkin Lymphoma                                                                  2.1%
                                                                                                                                                                                                                                           8            Thyroid Cancer                                                                            3%                               7 (tie)        Ovarian Epithelial Carcinoma                                                          2.1%
-- Analysis.                                                                                                                    AFAD population does not experience an average incidence.                                                  9            Urinary Bladder Cancer                                                                    2%                               9              Vulvar Carcinoma                                                                      1.4%
                                                                                                                                                                                                                                           10           Pancreatic Cancer                                                                         2%                               10 (tie)       Brain Neuroepithelial Carcinoma                                                       1.2%
    -- The population counts and cancer rates were for each year between 1989 and 2002, inclusive; they were                -- Medical services.                                                                                                                                                                                                                                   10 (tie)       Oral Squamous Cell Carcinoma                                                          1.2%
    stratified by age, gender, and race. Age strata included 15 to 19 yr, and then 5-yr intervals to 64 yr. Race                -- Oncology resources, cancer prevention efforts, and professional education programs may need to be
                                                                                                                                                                                                                                                        Total                                                                                     79%                                             Total                                                                                 88.1%

    strata included White, Black, Other, and Unknown. We calculated standardized incidence ratios (SIRs) and                    tailored to the AFAD population’s unique cancer type frequencies and distribution.                         1. U.S. general population cancer types are projections for 2005. Excludes cutaneous basal cell and squamous cell cancers. Adapted from Jemal A, Murray T, Ward E, et al., Cancer statistics, 2005, CA Cancer
                                                                                                                                                                                                                                           J Clin 2005; 55:10-30.
    their 95% CIs for all and the most frequently observed cancer types.                                                    -- Age considerations.                                                                                         2. U.S Air Force active duty population cancer types were for 1989-2002. Excludes cutaneous basal cell and squamous cell cancers.


                                                                                                                                -- AFAD cancer patients are relatively young, with clinical courses that may differ from those of older                                                                            Table 3. Selected U.S. Air Force Military Service-Related Factors and Their Possible Effects on Invasive Cancer Risks
                                                                                                                                persons. Healthcare providers may need to ensure oncologic treatment regimens and emotional support                                Cancer Types                                             Service Regulations                               Selection Bias                                  Behaviors                                         Healthcare Access

                                                                                                                                programs are effective for this younger patient cohort.                                                    Brain Neuroepithelial Carcinoma                                DQ: Li-Fraumeni syndrome 
                                                                                                                                                                                                                                                                                                          Possibly DQ: history of radiation treatment 
                                                                                                                            -- Directions for further research.                                                                            Breast Adenocarcinoma (females)                                Physical fitness requirements 
                                                                                                                                                                                                                                                                                                          Maximum body weight limits 
                                                                                                                                                                                                                                                                                                                                                                  Physically active lifestyle 
                                                                                                                                                                                                                                                                                                                                                                  Lesser prevalence of obesity 
                                                                                                                                                                                                                                                                                                                                                                                                        Possible higher prevalence of alcohol use          Increased access to oral contraceptives 
                                                                                                                                                                                                                                                                                                                                                                                                                                                            Increased access to estrogen replacements 
                                                                                                                                                                                                                                                                                                          DQ: breast-ovarian cancer syndrome, Cowden disease,
                                                                                                                                -- Detailed assessment of these cancer types could yield clues to etiologic or protective factors.                                                                        Li-Fraumeni syndrome 
                                                                                                                                                                                                                                                                                                          Possibly DQ: history of radiation treatment 
                                                                                                                                -- Measurement of risky sexual behaviors and human papilloma virus infection prevalence in the AFAD        Cervical Carcinoma                                                                                                                                           Possible higher prevalence of unsafe sex           Possible lesser use of condoms for contraception 
                                                                                                                                                                                                                                                                                                                                                                                                                                                            Increased access to screening 
                                                                                                                                population could help guide interventions against cervical and vulvar carcinomas.                          Colorectal Adenocarcinoma                                      Physical fitness requirements 
                                                                                                                                                                                                                                                                                                          Maximum body weight limits 
                                                                                                                                                                                                                                                                                                                                                                  Physically active lifestyle 
                                                                                                                                                                                                                                                                                                                                                                  Lesser prevalence of obesity 
                                                                                                                                                                                                                                                                                                          DQ: Crohn's disease, diabetes mellitus, familial
                                                                                                                                -- AFAD personnel may be a target population for future anti-human papilloma virus vaccines.                                                                              polyposis syndromes, ulcerative colitis 

                                                                                                                                                                                                                                                                                                          DQ: Cowden disease, xeroderma pigmentosum 
                                                                                                                                -- Measurement of general cancer incidence in the Air Force Reserve, Air National Guard, and other U.S.    Cutaneous Malignant Melanoma
                                                                                                                                                                                                                                           Hodgkin's Disease                                              DQ: human immunodeficiency virus infection 
                                                                                                                                                                                                                                           Non-Hodgkin Lymphoma                                           DQ: autoimmune disorders, immunodeficiency 
                                                                                                                                military service populations could provide a more complete epidemiologic picture.                          Oral Squamous Cell Carcinoma                                   Mandatory dental examinations                                                                Higher prevalence of cigarette smoking             Increased access to dental services 
                                                                                                                                                                                                                                                                                                                                                                                                        Possible higher prevalence of alcohol use 
                                                                                                                                -- Evaluation of the cancer experience of retirees, veterans, and discharged personnel may help            Ovarian Epithelial Carcinoma                                   DQ: breast-ovarian cancer syndrome 
                                                                                                                                                                                                                                                                                                          Possibly DQ: history of radiation treatment 
                                                                                                                                                                                                                                                                                                                                                                                                                                                            Increased access to oral contraceptives 
                                                                                                                                                                                                                                                                                                                                                                                                                                                            Increased access to estrogen replacements 
                                                                                                                                                                                                                                                                                                                                                                                                                                                            Increased access to tubal ligation 
                                                                                                                                determine whether the cancer incidence of active duty personnel is reduced or deferred post-service.       Prostate Adenocarcinoma                                        Physical fitness requirements                          Physically active lifestyle                                                              Increased access to screening 

                                                                                                                                -- Assessment of cancer mortality in the USAF can further characterize the service’s cancer burden.        Testicular Germ Cell Carcinoma
                                                                                                                                                                                                                                           Thyroid Follicular and/or Papillary Carcinoma
                                                                                                                                                                                                                                                                                                          DQ: cryptorchidism 
                                                                                                                                                                                                                                                                                                          Possibly DQ: history of radiation treatment 
                                                                                                                                                                                                                                           Urinary Bladder Transitional Cell Carcinoma (males)            Possibly DQ: history of radiation treatment                                                  Higher prevalence of cigarette smoking 
                                                                                                                                                                                                                                           Vulvar Carcinoma                                                                                                                                             Possible higher prevalence of unsafe sex 

                                                                                                                                                                                                                                           1. Legend: DQ = disqualifying;  = might increase risk for respective cancer type and  = might decrease risk for respective cancer type, compared to U.S. general population.
                                                                                                                                                                                                                                           2. Cancer types were the most frequently observed in U.S Air Force active duty population during 1989-2002. Excludes cutaneous basal cell and squamous cell cancers.

								
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