Early detection is the primary way to control breast cancer, and mammography screening can reduce breast cancer mortality 30 to 40 percent among women aged 50 years and older. Geographic areas with a high proportion of cases with late-stage diagnoses may reflect gaps in screening efforts. We used a spatial scan statistic, adjusting for the multitude of possible region locations and sizes, to test whether any particular region of Massachusetts had statistically significant excesses of late-stage diagnoses during the period 1982 to 1986. The novel geographic analysis technique utilized here can also be used in the control of other types of cancer.

Consumers of chlorinated drinking water have a small excess of bladder cancer. Risk may have been underestimated because of confounding and misclassification of exposure status. To address these problems, we undertook a case-control study. Detailed residential histories were obtained by telephone interviews with informants of 614 individuals who died of primarily bladder cancer and 1,074 individuals who died of other causes. Their surface water has been disinfected with chlorine or a combination of chlorine and ammonia (cloramine) since 1938. The mortality ratio for bladder cancer among individuals who resided only in communities supplied with drinking water disinfected with chlorine, relative to individuals who resided only in communities supplied with drinking water disinfected with chloramine, was 1.6 (95% confidence interval = 1.2-2.1), using all controls; when the comparison group was restricted to individuals who died of lymphoma, the mortality odds ratio was 2.7 (95% confidence interval = 1.7-4.3).

Chlorination has been the major strategy for disinfection of drinking water in the United States. Concern about the potential health effects of the reaction by-products of chlorine has prompted use of alternative strategies. One such method is chloramination, a treatment process that does not appear to have carcinogenic by-products, but may have less potent biocidal activity than chlorination.We examined the patterns of mortality of residents in Massachusetts who died between 1969 and 1983 and lived in communities using drinking water that was disinfected either by chlorine or chloramine.Comparison of type of disinfectant among 51,645 cases of deaths due to selected cancer sites and 214,988 controls who died from cardiovascular, cerebrovascular, or pulmonary disease, or from lymphatic cancer showed small variation in the patterns of mortality. Bladder cancer was moderately associated with residence at death in a chlorinated community (mortality odds ratio = 1.7, 95% confidence interval = 1.3-2.2) in a logistic regression analysis using controls who died from lymphatic cancer. A slight excess of deaths from pneumonia and influenza was observed in communities whose residents drank chloraminated water compared to residents from chlorinated communities, as well as to all Massachusetts residents (standardized mortality ratio = 118, 95% confidence interval = 116-120 for chloraminated communities, and standardized mortality ratio = 98, 95% confidence interval = 95-100 for chlorinated communities).These results are intended to be preliminary and crude descriptions of the relationship under study. The serious potential for misclassification of exposure status and errors in death certificate classification of cause of death affect the interpretability of the overall evidence that patterns of mortality are similar according to disinfectant in drinking water.

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In recent years a method of conducting mental health surveys has been developed which relies mainly on interviewing individuals according to a questionnaire. Subjects for the surveys are chosen by statistical techniques so that they will be representative of designated populations regardless of whether or not they have ever had psychiatric treatment. The questionnaires are administered by trained interviewers who as a rule are not psychiatrists; the data are later evaluated by psychiatrists who make a series of ratings on each individual in the survey. Inasmuch as surveys of this type show a very high prevalence of psychiatric disorder in many populations (from 10% to 60%), the question of validity becomes a matter of major importance. In the present study 123 individuals were examined and rated independently by both the survey technique and by a psychiatrist employing his usual clinical approach. After the psychiatrist had made his independent rating he was allowed to see the survey data and also to re-examine the subject again if he wished. He then made a final rating constituting his best judgment based on all information available. The degree of agreement is indicated in Tables I to IV. Table I deals with symptom patterns considered without regard to diagnostic implications. Thus, a given individual may have more than one of these symptom patterns. Table II concerns impairment by reason of psychiatric symptoms. Table III deals with a rating as to whether or not the subject is a psychiatric case: ‘A’ means almost certainly a psychiatric disorder of some sort; ‘B’ means probably; ‘C’ means doubtful; and ‘D’ means almost certainly not a psychiatric case. (Note that the group here studied was deliberately weighted with ‘A’ and ‘D’ ratings and hence is not representative of any population.) Table IV summarizes the agreements. While more work is needed, and studies of this kind should be repeated, the results so far show considerable agreement between the survey and clinical methods. This suggests that the large percentage figures obtained by surveys are properly matters of serious concern and that they have far-reaching implications for the teaching and practice of psychiatry.