1. Describe the following tests and under what circumstances you might use them over the others.

a. Chi-squared b. Fishers exact test of independence c. CochranMantelHaenszel test It is early February 2002, and news media around the country are reporting that Senator John McCain has been diagnosed with a recurring melanoma. Successful surgery follows, but the report has come on the heels of the death from melanoma of former President Reagan's daughter, Maureen Reagan. These high-profile cases focus attention on skin cancer, and you, as Chief Disease Detective for the State of Delaware, are asked to prepare a briefing for the governor on the problem nationally and in your state, and how to prevent it. A quick search of the data tells you that in 2001 doctors diagnosed approximately 51,400 new cases of melanoma, and about 7,800 people died of the disease. You locate data indicating that the incidence of melanoma has been on the rise since the early 1970s. The Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute collects and publishes cancer incidence and survival data from registries covering approximately 14% of the U.S. population. Using the SEER data in the table, answer the questions that follow. Figure 1. Age-adjusted incidence of melanoma by race and gender; SEER data, 19731998. (Source: National Cancer Institute)

2. Give the definition of incidence rate.

3. For some subgroups, the incidence rates appear to have increased overall in the past 20 years. Give two reasons for this apparent increase.

4. Referring to Figure 1, give the 1998 incidence rate for the following groups: White Men White Women Black Men Black Women ______________ ______________ ______________ ______________

5. Give two possible reasons for the observed large differences in incidence rates between races.

6. The rates in Figure 1 are age-adjusted. a. Define age adjustment and

b. explain why Disease Detectives would use age-adjusted rates. ANSWERS: Answer: 1. Describe the following tests and under what circumstances you might use them over the others. a) Chi-square is a statistical test commonly used to compare observed

data with data we would expect to obtain according to a specific hypothesis. Usually used to determine goodness of fit of expected values, and must have numerical values for variables having choices (usually yes or no). Better than b and c in cases with large numbers. b) Fishers exact test of independence is used when you have two nominal variables and is similar to the above except is more accurate in cases where the expected value is small.

c) Used when there are three nominal variables; you want to know whether two of the variables are independent of each other, and the third variable identifies the repeats, i.e. when you have the above conditions but want to control for a third variable (ex: time of year) on the correlation between the other two. 2. Give the definition of incidence rate. (3 points 1 each for explanation of numerator, denominator, and time) Answer: Incidence rate is a measure of the frequency with which a health problem or health event (such as a new injury or case of illness) occurs in a population. In calculating incidence, the numerator is the number of new cases occurring in the population during a given period of time, and the denominator is the total population at risk during that time. 3. For some subgroups, the incidence rates appear to have increased overall in the past 20 years. Give two reasons for this apparent increase. (2 points 1 for each valid reason) Answer: Factors that could contribute to the rise in rates include a. increased exposure to UV radiation as a result of more people being exposed to the sun (Note: This is the most important reason.); b. ozone depletion; c. heightened awareness among health care providers; d. increased reporting (improved surveillance); and e. people living longer increased survival. 4. Referring to Figure 1, give the 1998 incidence rate for the following groups: (8 points 2 for each rate. Estimates are acceptable; however, units must be cited. Take off 1 point for each rate without units.) Answer: a. White Men 19.3 per 100,000 persons b. White Women 13.6 per 100,000 persons c. Black Men 1.1 per 100,000 persons d. Black Women 1.0 per 100,000 persons

5. Give two possible reasons for the observed large differences in incidence rates between races. (2 points 1 for each valid reason) Answer: a. Racial and ethnic differences in observed rates are mostly due to skin color, which is determined by the amount of melanin produced by skin cells called melanocytes. Melanin also protects the skin from damage by UV radiation. Although darkly pigmented people (e.g., AfricanAmericans, Asians, Hispanics) develop skin cancer on sunexposed sites at lower rates than lightly pigmented people, UV exposure still increases their risk of skin cancer. b. Different cultures may have different prevention behaviors. c. Exposure may tend to be longer and more intense in some cultures than in others. d. Diagnosis may be more difficult when skin is highly pigmented. 6. The rates in Figure 1 are age-adjusted. (1) Define age adjustment and (2) explain why Disease Detectives would use age-adjusted rates. (2 points 1 for each part of the answer) Answer: a. Age adjustment is a statistical technique that uses the age distribution of a standard, or reference, population to adjust crude rates. Or, if actual methods for age adjustment are given: multiplication of an observed agespecific rate in each of two comparison groups by a standard population. b. Age-adjustment eliminates the effect of age on the data being compared, thus allowing Disease Detectives to compare incidence rates for different subgroups which otherwise may have different age distributions.