Series 2, Number 167 September 2014

Linkage of 1986–2009

National Health Interview

Survey With 1981–2010

Florida Cancer Data System
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Suggested citation

Miller EA, Miller DM, Judson DH, et al. Linkage of 1986–2009 National Health

Interview Survey with 1981–2010 Florida Cancer Data System. National Center

for Health Statistics. Vital Health Stat 2(167). 2014.

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Linkage of 1986–2009 National Health Interview Survey with 1981–2010 Florida

Cancer Data System.

p. ; cm.— (Vital and health statistics. Series 2, Data evaluation and methods

research ; number 167) (DHHS publication ; (PHS) 2014–1367)

‘‘September 2014.’’

Includes bibliographical references and index.

ISBN 978–0-8406–0667-9 (alk. paper)—ISBN 0–8406-0667–2 (alk. paper)

I. National Center for Health Statistics (U.S.), issuing body. II. Series: Vital and

health statistics. Series 2, Data evaluation and methods research ; no. 167. III.

Series: DHHS publication ; no. 2014–1367. 0276–4733

[DNLM: 1. National Health Interview Survey (U.S.) 2. Florida Cancer Data

System 3. Public Health—statistics & numerical data—United States. 4. Health

Surveys—United States. W2 A N148vb no.167 2014]

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Series 2, Number 167

Linkage of 1986–2009 National

Health Interview Survey With

1981–2010 Florida Cancer

Data System

Data Evaluation and Methods Research

Hyattsville, Maryland

September 2014

DHHS Publication No. 2014–1367

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Disease Control and Prevention

National Center for Health Statistics
National Center for Health Statistics

Charles J. Rothwell, M.S., M.B.A., Director

Jennifer H. Madans, Ph.D., Associate Director for Science

Office of Analysis and Epidemiology

Irma E. Arispe, Ph.D., Director
Contents

Abstract .................................................................................................. 1

Introduction ............................................................................................... 1

Methods .................................................................................................. 2

Data Files............................................................................................... 2

Linkage Approval and Methods ............................................................................. 2

Evaluation of Linked File .................................................................................. 4

Results ................................................................................................... 5

Linked NHIS–FCDS Data Files ............................................................................. 5

Discussion ................................................................................................ 7

Conclusion ................................................................................................ 9

References ................................................................................................ 9

Figures

1. Number of female participants available for breast cancer risk analysis using survey tobacco questions: 1986–2009

National Health Interview Survey linked with 1981–2010 Florida Cancer Data System ........................... 6

2. Percentage of diagnosed late-stage cancers, by education level and sex: 1986–2009 Florida National Health Interview

Survey participants aged 18 and over linked with 1981–2010 Florida Cancer Data System after interview ............ 7

3. Percentage of diagnosed late-stage cancers among those above and below federal poverty level, by sex: 1986–2009

Florida National Health Interview Survey participants aged 18 and over linked with 1981–2010 Florida Cancer Data

System after interview ............................................................................... 7

4. Percentage of diagnosed late-stage cancers, by marital status and sex: 1986–2009 Florida National Health Interview

Survey participants aged 18 and over linked with 1981–2010 Florida Cancer Data System after interview ............ 8

5. Percentage of self-rated fair and poor health status, by cancer diagnosis and sex: 1986–2009 Florida National Health

Interview Survey participants aged 18 and over linked with 1981–2010 Florida Cancer Data System before interview

(cancer survivor) and not linked (not diagnosed with cancer) ................................................ 8

6. Percentage having any activity limitation, by sex: 1986–2009 Florida National Health Interview Survey participants

aged 18 and over linked with 1981–2010 Florida Cancer Data System before interview (cancer survivor) and not linked

(not diagnosed with cancer) ........................................................................... 9

7. Percentage of current smokers, by sex: 1997–2009 Florida National Health Interview Survey participants aged 18 and

over linked with 1981–2010 Florida Cancer Data System before interview (cancer survivor) and not linked (not

diagnosed with cancer) ............................................................................... 9

Detailed Tables

1. Availability of selected questionnaire topics, by survey year: National Health Interview Survey, 1986–2009 . . . . . . . . . . 11

2. Number and percentage of linked participants, by demographic and cancer characteristics: 1986–2009 Florida National

Health Interview Survey participants aged 18 and over linked with 1981–2010 Florida Cancer Data System . . . . . . . . . 12

3. Number of linked participants and weighted percent distribution of survey and cancer time-period characteristics, by

sequence of survey and cancer diagnosis: 1986–2009 Florida National Health Interview Survey participants aged 18

and over linked with 1981–2010 Florida Cancer Data System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

4. Number and percentage of cancer types and demographic characteristics: 1986–2009 Florida National Health Interview

Survey participants aged 18 and over linked with Florida Cancer Data System (cancers diagnosed during 2006–2010)

compared with overall Florida Cancer Data System, 2006–2010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

iii
5. Cancer stage at diagnosis, by education level, poverty level, marital status, and sex: 1986–2009 Florida National

Health Interview Survey participants aged 18 and over linked with 1981–2010 Florida Cancer Data System after

interview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

6. Percentage of smoking status, self-rated health, and any activity limitation, by sex: 1986–2009 Florida National Health

Interview Survey participants aged 18 and over linked with 1981–2010 Florida Cancer Data System before interview

(cancer survivor) and not linked (not diagnosed with cancer) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

iv
Background

National survey data linked with

state cancer registry data has the

potential to create a valuable tool for

cancer prevention and control research.

A pilot project—developed in a

collaboration of the Centers for Disease

Control and Prevention’s National

Center for Health Statistics (NCHS) and

the Florida Cancer Data System

(FCDS) at the University of Miami

—links the records of the 1986–2009

National Health Interview Survey

(NHIS) and the 1981–2010 FCDS. The

project assesses the feasibility of

performing a record linkage between

NCHS survey data and a state-based

cancer registry, as well as the value of

the data produced. The linked

NHIS–FCDS data allow researchers to

follow NHIS survey participants

longitudinally to examine factors

associated with future cancer diagnosis,

and to assess the characteristics and

quality of life among cancer survivors.

Methods

This report provides a preliminary

evaluation of the linked national and

state cancer data and examines both

analytic issues and complications

presented by the linkage.

Conclusions

Residential mobility and the number

of years of data linked in this project

create some analytic challenges and

limitations for the types of analyses that

can be conducted. However, the linked

data set offers the ability to conduct

analyses not possible with either data

set alone.

Keywords: linkage • cancer registry

• data evaluation

Linkage of 1986–2009 National

Health Interview Survey With

1981–2010 Florida Cancer Data

System

by Eric A. Miller, Ph.D., Donna M. Miller, M.S., Dean H. Judson,

Ph.D., Yulei He, Ph.D., Hannah R. Day, Ph.D., Keith Zevallos, and

Jennifer D. Parker, Ph.D., National Center for Health Statistics; Jill

A. MacKinnon, Ph.D., Monique N. Hernandez, Ph.D., Brad Wohler,

M.S., and Recinda Sherman, Ph.D., Florida Cancer Data System,

University of Miami Miller School of Medicine; Christina A.

Fernandez, M.S.Ed., Laura A. McClure, M.S.P.H, William G. LeBlanc,

Ph.D., Stacey L. Tannenbaum, Ph.D., Diane D. Zheng, M.S., and

David J. Lee, Ph.D., University of Miami Miller School of Medicine;

and Sharon L. Christ, Ph.D., Purdue University

Introduction

This report describes a pilot linkage

between the 1986–2009 National Health

Interview Survey (NHIS) and the

1981–2010 Florida Cancer Data System

(FCDS), the cancer registry for Florida.

The report includes a preliminary

evaluation of the linked cancer data and

describes some of the analytic issues

and complications presented by the

linkage. This project is a collaboration

between FCDS at the University of

Miami and the Centers for Disease

Control and Prevention’s (CDC)

National Center for Health Statistics

(NCHS). Its goals are to demonstrate

and evaluate the feasibility of

performing a record linkage between

NCHS national sample survey data and

a state-based cancer registry, and to

assess the value and utility of the data it

produces. In addition to anticipated

cancer studies that would use the linked

data, information from the linkage

process can help inform future linkages

between sample survey data and cancer

registry data, and may be able to be

extrapolated to inform other linkages

between national sample surveys and

state data.

Linkage of NHIS with cancer

registry data can potentially produce a

valuable tool for cancer prevention and

control research. NHIS data contain

detailed demographic and health

information that is not available from

cancer registries. For example, NHIS

collects information on income,

education level, occupation and industry,

health insurance, and self-reported

health conditions. In addition, linking

multiple years of cancer registry data to

multiple survey years adds a

longitudinal component to the

cross-sectional survey data. For survey

participants interviewed before their

cancer diagnosis, researchers are able to

examine characteristics and risk factors

associated with future cancer diagnoses,

cancer stage at diagnosis, and survival

time. For survey participants interviewed

after a cancer diagnosis, researchers are

able to examine issues related to cancer

survival. Although NHIS asks

participants if they have ever been

Page 1
diagnosed with cancer, NHIS–FCDS

linked data allow researchers to examine

the health characteristics and quality of

life of cancer survivors in much greater

detail. For example, FCDS data provide

information about cancer stage at

diagnosis, which has a substantial

impact on cancer survival and future

quality of life. As a result, linkage

between these data sources provides

researchers with an opportunity to

conduct a wide array of cancer studies

and examine relationships not possible

with either data set alone.

Preliminary evaluation of the data

describes the results of the linkage and

compares the cancer types and

demographic characteristics of

participants in the linked file to cancer

patients represented in FCDS data alone.

In addition, some of the unique analytic

issues presented by the linkage of

multiple years of national health survey

data to multiple years of state-specific

cancer registry data are discussed.

Specifically, the creation of Floridaspecific survey weights, the potential

impact of residential mobility on the

linked file, and NHIS questionnaire and

sample design changes over time are

detailed. Finally, preliminary tabulations

of cancer variables by factors available

through NHIS are shown to illustrate

use of the linked file.

NHIS–FCDS data are restricted-use

data that can be accessed only by

approved researchers through the NCHS

Research Data Center (RDC). RDC

protects the confidentiality of survey

respondents by limiting access to

approved research proposals, providing a

secure work environment, and reviewing

researcher output for potential disclosure

risk.

Methods

Data Files

National Health Interview

Survey

NHIS is an annual, cross-sectional

household survey of the U.S. civilian

noninstitutionalized population (CNI)

conducted by NCHS since 1957. NHIS

serves as a principal source of

information on the health of the nation.

In addition to detailed demographic

information, NHIS collects a wide range

of health-related information including

health status and limitations, health care

access and utilization, health insurance,

and health behavior information

(including specific supplements on

cancer health behavior).

Prior to 1997, a core questionnaire,

including demographic information and

basic health questions, was used for

everyone in the household, with

supplemental questionnaires used for

more specific health topics. In 1997,

NHIS underwent a sample redesign and

questionnaire revision. While

demographic and basic health

information were still collected on

everyone in the household, one adult

and one child within each household

were randomly selected to conduct a

more detailed survey on more specific

health topics (1). These changes are

important for the linked data because

not all variables have been collected

from the entire sample or collected over

the entire file time period. This is

especially true for many cancer-related

variables that are not available from

cancer registry data, such as tobacco use

and cancer screening history. On the

other hand, a number of variables have

been collected across the entire survey

time period and are not typically

available from cancer registry data.

These include education level, income,

health insurance coverage, occupation

and industry, and body mass index

(derived from self-reported height and

weight). However, data collection in

many of these fields has changed

slightly over time. Table 1 provides

examples of variable availability by

survey year for selected topics in NHIS.

Florida Cancer Data System

Funded by Florida and CDC’s

National Program of Cancer Registries,

FCDS is the incidence cancer registry

for Florida. Cancer registries are

responsible for collecting, managing,

and analyzing data on incident cancer

cases and cancer deaths, and they are

essential in monitoring progress in

cancer prevention and control. With

more than 110,000 newly diagnosed

cancer cases per year, FCDS is the third

largest registry in the country and

represents approximately 6% of all U.S.

cancer cases. FCDS is ‘‘gold certified’’

by the North American Association of

Central Cancer Registries based on the

timeliness and completeness of the data

collected. FCDS began collecting data in

1981; however, the data system contains

cancer records dating to the 1950s,

either from voluntary reporting to the

Florida Department of Health prior to

FCDS or from previous diagnoses of

cancer among those with cancers

diagnosed from 1981 forward (2).

Cancer registries collect information

on the type of cancer, extent (i.e., stage

at diagnosis), initial treatment, and basic

demographic characteristics. Cancer

registries collect data at the tumor level;

therefore, persons diagnosed with more

than one incident cancer are included in

the registry for each tumor.

Approximately one-fifth of persons in

FCDS have been diagnosed with

multiple incident cancers. Tumors that

occur as a result of cancer cells

spreading (metastasis) from the original

location are not incident cancers. Cancer

registries are required to collect direct

identifiers in order to eliminate duplicate

records, consolidate multiple records,

and conduct follow-up on vital status

through data linkage with the NCHS

National Death Index.

Linkage Approval and

Methods

Designated Agent Agreement

and project approval

NHIS data are protected by Section

308(d) of the Public Health Service Act

and by the Confidential Information

Protection and Statistical Efficiency Act

(CIPSEA). Under CIPSEA legislation,

FCDS was required to sign a Designated

Agent Agreement, and all FCDS

analysts were required to complete

NCHS confidentiality training and

paperwork before accessing confidential

NCHS data to conduct the linkage.

Additionally, all NCHS record linkage

activities must be reviewed and

Page 2 [ Series 2, No. 167
approved by the NCHS Ethics Review

Board (ERB). ERB is a formally

appointed ethics review committee

established to ensure that research

involving human participants protects

their rights and welfare and conforms to

federal regulations. ERB granted

approval for the NHIS–FCDS data

linkage in May 2008. The project then

underwent review and approval by the

Florida Department of Health

Institutional Review Board, and the

linkage was initiated in spring 2009.

Linkage eligibility

To be eligible for FCDS linkage,

NHIS participants had to provide

sufficient direct identifiers [e.g., name,

date of birth, and Social Security

number (SSN)] and had not refused to

have their data linked. Linkage

eligibility requirements varied across

NHIS years due to changes in how ERB

determined whether a survey participant

was deemed eligible or ineligible for

linkage. Before 2007, participants who

refused to provide direct identifiers were

implicitly considered to have refused

record linkage. The refusal rate

increased between 1997 and 2006,

reducing the number of NHIS

participants eligible for record linkages.

Beginning in 2007, NHIS successfully

reduced linkage refusal rates by adding

a short introduction prior to the request

for SSN, requesting only the last four

digits of SSN rather than the full nine

digits, and asking participants who did

not provide SSN (or Medicare number)

for their explicit permission to link to

administrative records. Demographic

differences have been found between

those who refuse to provide an SSN and

those who do not (3), which could

potentially bias estimates calculated

from the linked data. Currently, this

issue is treated as a nonresponse bias,

and analytic methods are used to adjust

sample weights in an attempt to account

for differences (4).

NCHS submission file

preparation and description

NCHS provided FCDS with

electronic data files containing direct

identifiers and an NCHS-created control

number. The files used for matching did

not contain the NCHS survey public-use

identifiers available from the public-use

files. For the NHIS–FCDS linkage, all

NHIS survey participants meeting the

eligibility criteria, including non-Florida

residents, were submitted for linkage. A

match was not requested for participants

deemed ineligible for the linkage. The

data were securely sent to FCDS on an

encrypted CD.

Linkage process

FCDS used LinkPlus software (5) to

conduct the linkage. LinkPlus, which

CDC developed for cancer registries,

uses probabilistic linkage methods. In

addition to finding exact matches,

probabilistic methods can identify

matching records when not all matching

variables agree or when variables only

partially match. Records are given

scores for the number of matching or

partially matching fields, with certain

fields given more weight than others.

For example, matching on an SSN is

given more weight than matching on

place of residence.

For this linkage, matching scores

were based on SSN (nine and four

digits), date of birth, last name, first

name, middle initial, sex, race (white,

black, American Indian or Alaska

Native, Asian, other), five-character city

name, and five-digit zip code. The

city-name field was truncated to five

characters to improve matching

efficiency and reduce errors due to

misspellings or nonstandardized city

names. To account for possible

differences in first and last names due to

misspellings, alternative spellings, and

clerical errors, LinkPlus includes the

New York State Identification and

Intelligence System, or NYSIIS, which

is commonly used in data linkage to

convert names to phonetic codes.

Matches with scores of 30 and

above were considered true matches,

and scores below 17 were considered

false matches. Matches with scores from

17 through 29 were manually reviewed

to determine if they were true matches.

To assess the number of false or missed

matches, 100 consecutive records just

above and below the cutoffs were

reviewed. Of those above the

upper-score threshold, one false-positive

match was identified. Of those below

the lower threshold, matches appeared to

be missed in six records. The six

false-negative matches were all women

and fell just below the score cutoff,

primarily due to inconsistencies between

last names on the two files.

Processing of return file at

NCHS

The return file containing the

extracted FCDS data for matched NHIS

records was remerged with the

public-use survey identifiers to enable

the addition of survey data, and then

intermediate files were destroyed. The

return file was processed to create one

record per person. Because so few

children were linked with FCDS, the file

was limited to adults aged 18 and over

as of their NHIS interview. Variables

were added to provide linkage eligibility

status of survey participants and identify

survey participants who moved after the

survey interview. In addition, sample

weights appropriate to the linked data

were created and added to the file.

Creation of Florida-specific

sample weights

NHIS public-use and restricted-use

analytic survey files include annual

sample-weight variables, which are

inversely proportional to each

participant’s selection probability and

have been adjusted for oversampling of

specific subgroups and differential

nonresponse. NHIS sample weights are

intended to be representative of the CNI

population of the United States in each

survey year.

Although other approaches are

possible, sample weights for the linked

NHIS–FCDS data were created to

represent the CNI population of Florida.

The Florida-specific sample weights

were calculated for all linkage-eligible

NHIS participants, regardless of whether

they linked with FCDS. Because the

sample weights created for the linked

NHIS–FCDS data were representative of

the Florida CNI population in each

survey year, survey participants

interviewed in other states consequently

received a sample weight of zero, even

Series 2, No. 167 [ Page 3
if they linked with FCDS. As a result,

using the Florida CNI weighting

strategy, survey respondents interviewed

outside of Florida who later moved to

Florida where they were diagnosed with

cancer drop out of weighted analyses.

Two sets of Florida CNI sample

weights were created. The first were

created for all survey participants aged

18 and over in all NHIS years. An

additional sample-weight variable was

created to account for the sample

redesign and Sample Adult file

beginning in 1997. Because not all

NHIS participants were eligible for the

linkage, NHIS sample weights for

Florida residents at the time of survey

were first adjusted for linkage

ineligibility using PROC WTADJUST in

SUDAAN software (4). The adjusted

weights were then poststratified to the

estimated annual CNI population of

Florida for the corresponding survey

year. Two different sex- and age-specific

(18–39, 40–64, and 65 and over)

estimates of the annual Florida CNI

population were used to create the

poststratified weights. One method used

population estimates directly from NHIS

sample weights for each survey year

among Florida residents. Because of

substantial year-to-year variability

among population subgroups in earlier

years of NHIS, a second method used

total Florida population data from the

Florida Department of Health’s Office

of Health Statistics and Assessment

(available from: http://www.florida

charts.com/charts/default.aspx). This

method estimated the CNI proportion of

the total population using NHIS data

from 1997–2009, when CNI population

estimates were more stable. The first

step compared the Florida CNI

population data from NHIS to the total

Florida population for these 13 years to

calculate the average percent CNI

population over the time period. The

second step applied the average percent

CNI to the total Florida population data

over the entire time period covered by

the linkage, 1986–2009, to estimate the

CNI population for each survey year.

The two sample weights were highly

correlated (r = 0.99).

Evaluation of Linked File

To conduct the evaluation,

Integrated Health Interview Series

(IHIS) data, which harmonizes NHIS

data across survey years (6), were

merged with the linked file to obtain

several NHIS variables. For overall

evaluations, the following NHIS

variables collected at interview were

used: sex, age (18–39, 40–64, and 65

and over), race and ethnicity (nonHispanic white, non-Hispanic black,

Hispanic, and all other races and

ethnicities), educational level [less than

high school degree, high school

graduate/General Educational

Development (GED) certificate/some

college, post-high school degree], and

self-rated health status (excellent/very

good/good, fair/poor). IHIS

documentation contains further

information on how the collection and

subsequent harmonized coding of race

and ethnicity and education information

have changed over time (6). Except for

the presentation of unweighted numbers,

(see Results and Detailed Tables),

analysis of the file accounted for the

complex survey design, and estimates

were weighted using the Florida-specific

sample weights created for this file.

Comparisons of unweighted percentages

were not statistically tested.

Evaluation of NCHS–FCDS data

first consisted of an overall description

of NHIS participants who were linked

with FCDS, including the unweighted

and weighted distributions of

demographic and cancer characteristics

in the linked population. Because linked

NHIS participants who were not

residents of Florida at the time of

survey receive a zero weight and drop

out of weighted analyses, an assessment

was made of how their characteristics

differed from the linked NHIS

participants who were Florida residents

at the time of survey. Additional

weighted examinations of cancer types

and characteristics related to the linkage

time period were made by sequence of

cancer diagnosis and survey

participation.

To assess the representativeness of

the linked cancer cases in NHIS–FCDS

data relative to all Florida cancer cases,

the demographic characteristics and

cancer types were examined for Florida

linked survey participants and the

unlinked FCDS data for 2006–2010, the

most current 5 years of data available

for analysis. The evaluation was limited

to survey participants who had their first

cancers diagnosed during 2006–2010

and those diagnosed after survey

participation, to examine incident

cancers only. Because the two groups

are not statistically independent,

comparisons were not statistically tested.

Due to the potential loss of sample

size from linkage ineligibility, weights

that were specific to Florida residents at

the time of survey, and the

unavailability of certain variables during

the linkage time period, an examination

was made of how these factors could

affect an analysis of the linked

NHIS–FCDS data. Specifically, the

reduction in sample size after

accounting for each of these factors was

documented, using a hypothetical

analysis of female breast cancer and

tobacco use as an example.

As an initial analysis of the linked

data, basic statistics available from the

linked NHIS–FCDS data but not

available from either data source alone

were calculated to examine preliminary

relationships between demographic and

health factors and cancer. For this

analysis, an examination was made of

the relationship between cancers

diagnosed at a late stage (i.e., with

tumor having spread regionally or to a

distant site in the body) and

demographic characteristics of those

who were linked with FCDS. In

addition, selected health characteristics

were compared between cancer

survivors (survey participants linked

with FCDS prior to their survey

interview) and survey participants who

had not been diagnosed with cancer

(participants not linked with FCDS). All

estimates were calculated overall and by

sex. Other information from IHIS used

for this evaluation included marital

status (married, not married/widowed/

separated), smoking status (never,

current, former), and poverty status

based on income above or below the

federal poverty level. Poverty

Page 4 [ Series 2, No. 167
status used the POORYN variable from

IHIS, which is based on income and

family size and its relation to the

poverty threshold set by the U.S. Census

Bureau for each survey year (6). Income

is not imputed for this variable; as a

result, data were missing from 676

Florida NHIS participants who were

linked with FCDS (11.4%). The

demographic variables and activity

limitation variable were available for all

years of NHIS. Because smoking status

was available only for select years

before 1997 and was not always

collected on the full sample, smoking

estimates reported here were based on

sample adults in 1997–2009 NHIS data.

Results

Linked NHIS–FCDS Data

Files

Characteristics of linked survey

participants

NHIS participants aged 18 and over

totaled 1,708,723 during 1986–2009.

Approximately one-third of the

participants were ineligible for the

linkage (n = 575,327). After running

LinkPlus and performing manual review,

NHIS participants who were linked with

FCDS totaled 8,210. For this report,

linked records with cancers missing a

date of diagnosis (n = 59) or cancers

reported prior to 1981 with no

additional cancers diagnosed after 1981

were excluded (n = 41).

Of the remaining 8,110 linked

participants, 1,443 (17.8% unweighted)

were linked with more than one tumor

in FCDS (Table 2). Approximately

one-half (unweighted) of the linked

survey participants were men (50.2%),

approximately 90% were aged 40 and

over at the time of survey (89.9%), and

more than 70% were non-Hispanic

white (73.3%). Almost two-thirds

(unweighted) of the linked participants

(65.0%) were interviewed during

1986–1996; the remaining 35.0% were

interviewed during 1997–2009, after the

NHIS sample and questionnaire

redesign. By time period of cancer

diagnosis, 46.0% (unweighted) of linked

participants had cancers diagnosed

during 1996–2005.

When the Florida-specific weights

were applied, limiting the analysis to

Florida residents at the time of survey,

the percentage of linked participants

who were Hispanic decreased and the

percentage of participants aged 65 and

over increased (Table 2). This difference

between the unweighted and weighted

distributions is likely a result of the

weights accounting for the oversampling

of Hispanic participants in the NHIS

survey design. In addition, limiting the

sample to Florida residents at the time

of survey resulted in a larger percentage

of linked survey participants from

survey years 1997–2009 and with 0–5

years between survey and cancer

diagnosis.

The total number of NHIS–FCDS

linked participants interviewed outside

of Florida was 1,829, 22.6%

(unweighted) of all linked participants.

Although not statistically tested, the

sample of non-Florida linked survey

participants had higher percentages

(unweighted) of men, non-Hispanic

white persons, and post-high school

degrees than the Florida linked survey

participants. Possibly due to being

healthy enough to move, 85.3%

(unweighted) of the sampled non-Florida

linked survey participants reported

excellent/very good/good health status at

the time of survey; 76.7% (unweighted)

of Florida linked survey participants

reported excellent/very good/good health

status. The majority of non-Florida

linked participants were interviewed

during 1986–1996 and close to 80%

(unweighted) of their cancers (78.9%)

were diagnosed during 1996–2010.

Table 3 presents the number and

distribution of cancers among linked

Florida participants by sequence of

cancer diagnosis related to survey

participation. The cancer cases were

limited to the first cancer diagnosis

among those who were linked to more

than one cancer. The majority of linked

survey participants were diagnosed with

cancer after they had participated in the

survey, which allows researchers to

examine the characteristics and health

behaviors of survey participants before

they were diagnosed with cancer.

Among five commonly diagnosed

cancers (prostate, female breast, lung,

colorectal, and bladder), the number of

cases ranged from 200 to 724 when the

cancer was diagnosed after survey

participation. More than 60% of linked

participants with cancer diagnosed after

the survey (63.6%) were interviewed

during 1986–1996, and 84.3% of the

cancers were diagnosed during

1996–2010. When examining the length

of time between survey and cancer

diagnosis, 44.3% of the linked survey

participants were diagnosed within 5

years after the interview.

A total of 1,908 linked survey

participants had cancer diagnosed before

participating in NHIS (Table 3). The

number of cases for the specific cancer

types ranged from 89 to 403. Consistent

with poor survival among patients

diagnosed with lung cancer, the

proportion of lung cancer survivors was

substantially smaller for linked survey

participants diagnosed with cancer

before rather than after the survey

interview. Additionally, the slightly

higher percentages of breast and prostate

cancers among cancer survivors may be

due to the fact that many of these

cancers are diagnosed at an early stage

and have high survival rates when

detected early (7). Approximately

two-thirds (weighted) of linked survey

participants with a cancer diagnosis

prior to the survey (66.8%) were aged

65 and over at the time of survey. By

time period, 67.5% (weighted) of linked

survey participants with a previous

cancer diagnosis were interviewed

during 1997–2009, and 79.9% of the

cancers were diagnosed during

1986–2005. More than one-half

(weighted) were interviewed within 5

years from their cancer diagnosis date in

FCDS (53.5%).

Comparison with unlinked

FCDS

By inspection, the five commonly

diagnosed cancers among Florida linked

survey participants diagnosed during

2006–2010 were consistent with

unlinked FCDS data, with some

exceptions. For example, female breast

cancer was the most commonly

diagnosed cancer among Florida survey

Series 2, No. 167 [ Page 5
participants, and lung cancer was the

most commonly diagnosed cancer in the

unlinked FCDS data (Table 4). By sex, a

similar percentage of men and women

are represented in the linked data, but

the percentage of men in the unlinked

FCDS data is 53.2%. The racial and

ethnic distribution of Florida linked

survey participants was generally similar

to those with cancer diagnosis in the

unlinked FCDS, except that the

estimated percentage of non-Hispanic

black linked survey participants was

higher than the corresponding

percentage in the unlinked FCDS.

Potential loss of analytic sample

size in linked NCHS–FCDS

data analysis

Although the large annual sample

populations of NHIS make this linkage

possible, not all participants can be

included in analyses of the linked data

for various reasons. This loss of analytic

sample size can substantially reduce the

power of certain analyses or the ability

to examine differences between

subgroups, and can introduce bias if

differences exist between those who are

included in the sample and those who

are not. For example, consider tobacco

use and breast cancer risk (Figure 1): Of

the 911,262 women aged 18 and over in

NHIS during 1986–2009, 49,550 were

interviewed in Florida. Of those, 18,626

were ineligible for linkage. After

excluding women diagnosed with other

cancers in FCDS, 27,714 women

without cancer and 724 women

diagnosed with breast cancer were

available for analysis. However, to

conduct an analysis based on tobacco

use, which was not collected every year

or from the full sample, data are

available only for 10,989 women

without cancer and 259 with breast

cancer. Similarly, questions regarding

cancer screening and family history of

cancer were included only in select

years with NHIS cancer supplemental

questionnaires. Of the same 724 breast

cancer cases, information on previous

mammography use is available only for

112 women.

Initial analysis of linked

NCHS–FCDS data

The weighted percentage of

participants diagnosed with late-stage

cancer in the linked NHIS–FCDS data

was greater with decreasing education

level for both men and women

(Figure 2, Table 5). Men (4.0%) and

women (2.0%) with a post-high school

degree were less likely to be diagnosed

with late-stage cancer compared with

those having less than a high school

degree (8.0% men and 6.6% women).

Similarly, men (5.1%) and women

(3.8%) living above the federal poverty

level were less likely to be diagnosed

with a late-stage cancer compared with

those below the federal poverty level

(12.6% men and 9.0% women), but this

difference was statistically significant

only among men (Figure 3, Table 5). By

marital status, only married women were

significantly less likely to be diagnosed

with a late-stage cancer (2.9%)

compared with those who were not

married/divorced/separated (6.2%)

(Figure 4, Table 5); however, married

men were significantly more likely to be

diagnosed with late-stage cancer than

married women.

When comparing health

characteristics of cancer survivors

(Florida NHIS participants who were

linked to FCDS prior to survey) with

those who had not been diagnosed with

cancer (Florida participants not linked

with FCDS before or after interview),

the weighted percentage of cancer

survivors reporting they were in

fair/poor health (33.2%) was more than

double that of participants who had not

been diagnosed with cancer (13.0%)

(Figure 5, Table 6). This association was

true for both men and women. Cancer

survivors were also more likely to report

having some type of activity limitation

compared with those not diagnosed with

cancer (Figure 6, Table 6). Both men

(40.1%) and women (36.1%) who were

cancer survivors were more than twice

as likely to report having an activity

limitation compared with those who had

Number of female Florida NHIS participants,

1986–2009:

49,550 

Number of linkage-eligible female Florida

NHIS participants, 1986–2009:

30,924

Not linkage-eligible

n = 18,626

Excluding other cancers

n = 2,486

Not asked about 

tobacco use

n = 465

Not asked about 

tobacco use

n = 16,725

No cancer

(not linked with FCDS):

27,714

Answered tobacco questions

from available survey years1

:

10,989

Answered tobacco questions

from available survey years1:

259

Breast cancer

(linked with FCDS):

724

1

See Table 1 of this report for details on the availability of tobacco questions across NHIS years.

NOTE: NHIS is National Health Interview Survey; FCDS is Florida Cancer Data System.

SOURCE: CDC/NCHS, 1986–2009 National Health Interview Survey linked with 1981–2010 Florida Cancer

Data System. 

Figure 1. Number of female participants available for breast cancer risk analysis using

survey tobacco questions: 1986–2009 National Health Interview Survey linked with

1981–2010 Florida Cancer Data System

Page 6 [ Series 2, No. 167
not been diagnosed with cancer (14.4%

men and 16.4% women). Among those

interviewed during 1997–2009, the

percentage of cancer survivors who

were current smokers at the time of

survey was less than 11% for both men

and women (Figure 7, Table 6),

approximately one-half the percentage

among women (20.2%) and less than

one-half the percentage among men

(25.0%) who had not been diagnosed

with cancer.

Discussion

The linked NHIS–FCDS data allow

researchers to follow NHIS survey

participants longitudinally to examine

factors associated with future diagnosis

of cancer and to assess the

characteristics and quality of life among

cancer survivors. FCDS data provide

detailed information on the type of

cancer and stage at diagnosis, while

NHIS provides detailed

sociodemographic information and

extensive self-reported data on health

characteristics, including health

conditions, access to health care, and

health care utilization that are not

available from cancer registry data. For

example, using education and poverty

level, the linked data allow researchers

to examine socioeconomic

characteristics at the individual level

rather than relying on census tract-level

estimates, which is the common

approach. Using self-rated health and

the presence of an activity limitation as

another example demonstrates the data

set’s ability to assess morbidity among

cancer survivors.

Overall, the linked NHIS–FCDS

data had a similar distribution of major

cancer types compared with unlinked

FCDS data, with a slight overrepresentation of breast cancer, which

may be explained by a higher

percentage of women in the linked data.

The linked NHIS–FCDS data also had a

slightly higher percentage of nonHispanic black cancer cases than the

unlinked FCDS data. This could result

from oversampling in NHIS that was

not fully adjusted for in the new

weights.

Residential mobility proved to be

one of the major challenges with the

linked NCHS–FCDS data. While the

current weighting strategy (creating

weights to the year of the survey) is

valid, it results in a nontrivial reduction

in sample size by giving a zero weight

to linked NHIS participants who were

interviewed in other states but were

diagnosed with cancer in Florida.

Alternative weighting strategies are

being investigated to reduce the loss of

sample size. However, noticeable

differences were observed between the

* Figure does not meet standards of reliability or precision; relative standard error is greater than 30%.

NOTES: Late-stage cancers include tumors that have spread regionally or to distant sites of the body at diagnosis.

GED is General Educational Development high school equivalency diploma. Confidence interval is 95%. 

SOURCE: CDC/NCHS, 1986–2009 National Health Interview Survey linked with 1981–2010 Florida Cancer

Data System.

Overall Men Women

Weighted percent

0

5

10

15

Less than high school High school graduate/

GED/some college

Post-high school

degree

*

Figure 2. Percentage of diagnosed late-stage cancers, by education level and sex:

1986–2009 Florida National Health Interview Survey participants aged 18 and over linked

with 1981–2010 Florida Cancer Data System after interview

* Figure does not meet standards of reliability or precision; relative standard error is greater than 30%. 

NOTES: Late-stage cancers include tumors that have spread regionally or to distant sites of the body at diagnosis. 

Confidence interval is 95%. 

SOURCE: CDC/NCHS, 1986–2009 National Health Interview Survey linked with 1981–2010 Florida Cancer

Data System. 

0

5

10

15

20

Overall Men Women

Weighted percent

Below poverty level Above poverty level

*

Figure 3. Percentage of diagnosed late-stage cancers among those above and below

federal poverty level, by sex: 1986–2009 Florida National Health Interview Survey

participants aged 18 and over linked with 1981–2010 Florida Cancer Data System after

interview

Series 2, No. 167 [ Page 7
demographic characteristics of

non-Florida residents who were linked

with FCDS and the demographic

characteristics of linked Florida

participants, and caution is needed to

not bias inference by including

non-Florida residents without

appropriate methods.

Out-migration is another potential

problem in the data set. In this case, all

survey participants from Florida are

given a Florida sample weight for

analysis of the linked NHIS–FCDS data,

but it is not possible to identify if some

of these participants moved or were

diagnosed with cancer in another state.

The number of survey participants who

were Florida residents at the time of

interview but moved out of Florida after

the interview is unknown, but the

number may not be trivial. Of the 3,526

deaths among Florida survey

participants who were linked with

FCDS, 7.8% (n = 275) died in another

state.

The loss of NHIS participants from

the study population, due either to

linkage ineligibility or migration, may

adversely affect the generalizability of

study inferences or the ability to

calculate accurate prevalence estimates.

Although the sample weights used for

the estimates in this report were

adjusted for linkage ineligibility and

calibrated to the Florida population, it is

unclear how differences in

characteristics may influence results

between those who are linkage eligible

and those ineligible, as well as between

those who migrated into or out of

Florida compared with those who were

constant Florida residents.

Using 23 years of NHIS data

allowed for a sufficient number of

Florida NHIS participants to be linked

with FCDS to conduct many types of

data analyses. However, changes in the

questionnaire during this time period

limit some types of analyses as well as

the ability to control for potential

confounders. While NHIS data from

1997 forward are more consistent, the

number of cancers diagnosed from those

survey years limits the ability to

examine many individual types of

cancer; linkage eligibility criteria and

the provision of SSN also changed

during the time period, further reducing

the study population. In addition, survey

responses may not be representative for

time-variant characteristics because of

the potential for a substantial number of

years to elapse between the survey and

cancer diagnosis. Among participants

diagnosed with cancer after their survey

participation, nearly 60% had more than

5 years elapse between survey and

cancer diagnosis (55.7%). For

time-variant characteristics such as

Married Not married/widowed/separated

NOTES: Late-stage cancers include tumors that have spread regionally or to distant sites of the body at diagnosis. 

Confidence interval is 95%. 

SOURCE: CDC/NCHS, 1986–2009 National Health Interview Survey linked with 1981–2010 Florida Cancer

Data System. Weighted percent

0

5

10

15

Overall Men Women

Figure 4. Percentage of diagnosed late-stage cancers, by marital status and sex:

1986–2009 Florida National Health Interview Survey participants aged 18 and over linked

with 1981–2010 Florida Cancer Data System after interview

NOTES: Cancer survivors are survey participants whose data were linked with the Florida Cancer Data System

before their survey interview; those not diagnosed with cancer were not linked with the data system.Confidence

interval is 95%. 

SOURCE: CDC/NCHS, 1986–2009 National Health Interview Survey linked with 1981–2010 Florida Cancer

Data System. 

Overall Men Women

Weighted percent

0

10

20

30

40

50

Cancer survivor Not previously diagnosed with cancer

Figure 5. Percentage of self-rated fair and poor health status, by cancer diagnosis and

sex: 1986–2009 Florida National Health Interview Survey participants aged 18 and over

linked with 1981–2010 Florida Cancer Data System before interview (cancer survivor) and

not linked (not diagnosed with cancer)

Page 8 [ Series 2, No. 167
health insurance coverage or meeting

cancer screening guidelines, the survey

response may not be representative of

the full interval from or until cancer

diagnosis.

Conclusion

The pilot linkage of NHIS and

FCDS demonstrates the feasibility of

linking national-level sample survey

data with state-based cancer registry

data. The linked data set provides the

ability to conduct analyses that are not

possible with either data set alone.

NHIS adds participant-level

characteristics that are highly desired

among researchers using cancer registry

data, and FCDS provides detailed

outcome information for those who are

diagnosed with cancer after survey

participation and detailed baseline

information for cancer survivors who

participate in the survey after their

cancer diagnosis. The number of years

of data linked in this project creates

some analytic challenges, and limitations

exist in the types of analyses that can be

conducted. For example, the loss of

sample due to linkage eligibility and

mobility in and out of Florida make the

data more suited for examining

relationships among factors than for

other uses, such as prevalence estimates.

The methodological issues encountered

with these data may be relevant to other

national and state data linkages.

References

1. National Center for Health Statistics.

1997 National Health Interview Survey

(NHIS) public use data release. 2000.

Available from: ftp://ftp.cdc.gov/pub/

Health_Statistics/NCHS/Dataset_

Documentation/NHIS/1997/

srvydesc.pdf.

2. Florida Cancer Data System (FCDS).

2014. Available from: http://fcds.med.

miami.edu/inc/welcome.shtml

[Accessed February 18, 2014].

3. Miller DM, Gindi RM, Parker JD.

Trends in record linkage refusal rates:

Characteristics of National Health

Interview Survey participants who

refuse record linkage. Paper presented

at the 2011 meeting of the Joint

Statistical Meeting, July 30–August 4,

2011, Miami Beach, FL. 2011.

4. Judson DH, Parker JD, Larsen MD.

Adjusting sample weights for

linkage-eligibility using SUDAAN.

Hyattsville, MD: National Center for

Health Statistics. 2013. Available from:

http://www.cdc.gov/nchs/data/

datalinkage/adjusting_sample_

weights_for_linkage_eligibility_using_

sudaan.pdf.

NOTES: Cancer survivors are survey participants whose data were linked with the Florida Cancer Data System

before their survey interview; those not diagnosed with cancer were not linked with the data system. Confidence

interval is 95%. 

SOURCE: CDC/NCHS, 1986–2009 National Health Interview Survey linked with 1981–2010 Florida Cancer

Data System. 

Overall Men Women

Weighted percent

0

10

20

30

40

50

Cancer survivor Not previously diagnosed with cancer

Figure 6. Percentage having any activity limitation, by sex: 1986–2009 Florida National

Health Interview Survey participants aged 18 and over linked with 1981–2010 Florida

Cancer Data System before interview (cancer survivor) and not linked (not diagnosed with

cancer)

NOTES: Current smokers have smoked at least 100 cigarettes in their lifetime and still currently smoke. Cancer

survivors are survey participants whose data were linked with the Florida Cancer Data System before their survey 

interview; those not diagnosed with cancer were not linked with the data system. Confidence interval is 95%.

SOURCE: CDC/NCHS, 1997–2009 National Health Interview Survey linked with 1981–2010 Florida Cancer

Data System. 

Overall Men Women

Weighted percent

Cancer survivor Not previously diagnosed with cancer

0

5

10

15

20

25

30

Figure 7. Percentage of current smokers, by sex: 1997–2009 Florida National Health

Interview Survey participants aged 18 and over linked with 1981–2010 Florida Cancer Data

System before interview (cancer survivor) and not linked (not diagnosed with cancer)

Series 2, No. 167 [ Page 9
5. Centers for Disease Control and

Prevention. Registry Plus Link Plus.

Available from: http://www.cdc.gov/

cancer/npcr/tools/registryplus/lp.htm

[Accessed July 15, 2014].

6. Minnesota Population Center and State

Health Access Data Assistance Center.

Integrated Health Interview Series

(Version 5.0). Minneapolis, MN:

University of Minnesota. 2012.

Available from: https://www.ihis.us/ihis/

[Accessed March 12, 2014].

7. American Cancer Society. Cancer Facts

& Figures 2013. Atlanta, GA. 2013.

Page 10 [ Series 2, No. 167
stionnaire topics, by survey year: National Health Interview Survey, 1986–2009

Survey year

1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

1X ... ... X X 2

X 3

X 1

X 1X ... 4

X 4

X 4

X 4

X 4

X 4

X 4

X 4

X 4

X 4

X 4

X 4

X 4

X

X X ... X X X ... ... ... ... 4

X 4

X 4

X 4

X 4

X 4

X 4

X 4

X 4

X 4

X 4

X 4

X 4

X

... ... ... ... ... ... ... ... ... ... ... ... ... 4X ... ... ... ... 4X ... ... ... ...

X ... ... X ... X ... ... ... ... ... ... 4

X 4X ... ... 4X ... 4X ... ... 4X ...

5X ... ... ... ... 5X ... ... ... ... ... ... ... 4X ... ... 4X ... 4X ... ... 4X ...

X X X X X X X X X X X X XX X X X XX X X X X

X X X X X X X X X X X X XX X X X XX X X X X

X X X X X X X X X X X X XX X X X XX X X X X

X X X X X X X X X X X X XX X X X XX X X X X

X X X X X X X X X X X X XX X X X XX X X X X

n.

collection.

h partial-year data collection.

Survey, 1986–2009.

Series 2, No. 167 [ Page 11
Table 2. Number and percentage of linked participants, by demographic and cancer characteristics: 1986–2009 Florida National Health

Interview Survey participants aged 18 and over linked with 1981–2010 Florida Cancer Data System

Characteristic

All linked survey participants1 Florida residents at time of survey1 Non-Florida residents at time of survey1

Unweighted

number

Unweighted

percent

Unweighted

number

Unweighted

percent

Weighted

percent

Unweighted

number

Unweighted

percent

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8,110 100.0 6,281 100.0 100.0 1,829 100.0

Number of linked tumors

One. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6,667 82.2 5,147 82.0 81.9 1,520 83.1

More than one . . . . . . . . . . . . . . . . . . . . . . 1,443 17.8 1,134 18.0 18.1 309 16.9

Sex

Male . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4,074 50.2 3,110 49.5 50.6 964 52.7

Female. . . . . . . . . . . . . . . . . . . . . . . . . . . 4,036 49.8 3,171 50.5 49.4 865 47.3

Age (years)

18–39 . . . . . . . . . . . . . . . . . . . . . . . . . . . 821 10.1 607 9.7 9.2 214 11.7

40–64 . . . . . . . . . . . . . . . . . . . . . . . . . . . 3,784 46.7 2,730 43.5 42.1 1,054 57.6

65 and over . . . . . . . . . . . . . . . . . . . . . . . . 3,505 43.2 2,944 46.9 48.7 561 30.7

Race and ethnicity

Hispanic . . . . . . . . . . . . . . . . . . . . . . . . . . 1,066 13.1 971 15.5 10.9 95 5.2

Non-Hispanic white . . . . . . . . . . . . . . . . . . . 5,944 73.3 4,330 68.9 76.4 1,614 88.2

Non-Hispanic black . . . . . . . . . . . . . . . . . . . 978 12.1 881 14.0 11.1 97 5.3

Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122 1.5 99 1.6 1.6 23 1.3

Education level

Less than high school. . . . . . . . . . . . . . . . . . 1,826 22.7 1,523 24.5 21.4 303 16.6

High school graduate, GED, or some college . . . 4,562 56.8 3,498 56.3 57.7 1,064 58.4

Post-high school degree . . . . . . . . . . . . . . . . 1,643 20.5 1,188 19.1 20.9 455 25.0

Missing. . . . . . . . . . . . . . . . . . . . . . . . . . . 79 . . . 72 . . . . . . 7 . . .

Self-rated health

Excellent, very good, or good . . . . . . . . . . . . . 6,356 78.7 4,800 76.7 77.1 1,556 85.3

Fair or poor . . . . . . . . . . . . . . . . . . . . . . . . 1,724 21.3 1,455 23.3 22.9 269 14.7

Missing. . . . . . . . . . . . . . . . . . . . . . . . . . . 30 . . . 27 . . . . . . 4 . . .

Survey years

1986–1996 . . . . . . . . . . . . . . . . . . . . . . . . 5,271 65.0 3,782 60.2 52.6 1,489 81.4

1997–2009 . . . . . . . . . . . . . . . . . . . . . . . . 2,839 35.0 2,499 39.8 47.4 340 18.6

Cancer diagnosis2

Before 1986. . . . . . . . . . . . . . . . . . . . . . . . 443 5.5 354 5.6 5.7 89 4.9

1986–1995 . . . . . . . . . . . . . . . . . . . . . . . . 1,991 24.6 1,694 27.0 25.4 297 16.2

1996–2005 . . . . . . . . . . . . . . . . . . . . . . . . 3,705 45.7 2,812 44.8 45.0 893 48.8

2006–2010 . . . . . . . . . . . . . . . . . . . . . . . . 1,971 24.3 1,421 22.6 23.9 550 30.1

Years between survey and cancer diagnosis2

0–5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3,307 40.8 2,861 45.5 47.6 446 24.4

6–10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2,192 27.0 1,720 27.4 26.7 472 25.8

More than 10 . . . . . . . . . . . . . . . . . . . . . . . 2,611 32.2 1,700 27.1 25.8 911 49.8

. . . Category not applicable.

1Cancer identified through linkage with the Florida Cancer Data System could have occurred before or after survey participation.

2Estimates limited to first cancer diagnosis among participants with more than one cancer diagnosis in the Florida Cancer Data System.

NOTE: GED is General Educational Development high school equivalency diploma.

SOURCE: CDC/NCHS, 1986–2009 National Health Interview Survey linked with 1981–2010 Florida Cancer Data System.

Page 12 [ Series 2, No. 167
Table 3. Number of linked participants and weighted percent distribution of survey and cancer time-period characteristics, by sequence of

survey and cancer diagnosis: 1986–2009 Florida National Health Interview Survey participants aged 18 and over linked with 1981–2010

Florida Cancer Data System

Characteristic

Florida residents at time

of survey with interview

before cancer diagnosis1

Florida residents at time of

survey with cancer diagnosis

before interview1

Unweighted

number

Weighted

percent

Unweighted

number

Weighted

percent

Total. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4,367 100.0 1,908 100.0

Cancer type

Female breast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 724 16.4 401 20.9

Prostate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 666 14.8 403 21.2

Lung . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 613 14.4 89 4.1

Colorectal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 446 10.2 233 12.0

Bladder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200 4.4 120 6.4

All others. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,716 39.8 662 35.4

Missing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 . . . . . . . . .

Age at survey (years)

18–39. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 521 11.7 86 4.6

40–64. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2,165 49.5 561 28.6

65 and over . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,681 38.9 1,261 66.8

Survey years

1986–1996. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3,013 63.6 765 32.5

1997–2009. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,354 36.4 1,143 67.5

Cancer diagnosis

Before 1986 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 349 16.1

1986–1995. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 753 15.7 941 43.2

1996–2005. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2,235 49.5 576 36.7

2006–2010. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,379 34.8 42 4.0

Years between survey and cancer diagnosis

0–5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,778 44.3 1,082 53.5

6–10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,239 27.2 481 25.8

More than 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,350 28.5 345 20.7

. . . Category not applicable.

1Estimates limited to first cancer diagnosis among participants with more than one cancer diagnosis in the Florida Cancer Data System.

SOURCE: CDC/NCHS, 1986–2009 National Health Interview Survey linked with 1981–2010 Florida Cancer Data System.

Series 2, No. 167 [ Page 13
Table 4. Number and percentage of cancer types and demographic characteristics: 1986–2009 Florida National Health Interview Survey

participants aged 18 and over linked with Florida Cancer Data System (cancers diagnosed during 2006–2010) compared with overall Florida

Cancer Data System, 2006–2010

Characteristic

Florida residents at time of survey and

cancer diagnosed during 2006–2010

Florida Cancer Data

System, 2006–20101

Unweighted

number

Weighted

percent

Confidence

interval2

Unweighted

number

Unweighted

percent

Cancer type

All cancers................................ 1379 100.0 . . . 527,730 100.0

Female breast . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242 17.3 14.9–20.0 68,618 13.0

Prostate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187 13.0 11.2–15.0 73,746 14.0

Lung . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172 13.0 11.3–15.0 81,023 15.4

Colorectal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131 9.7 7.6–12.4 49,592 9.4

Bladder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 4.2 3.3–5.2 24,978 4.7

All others . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 593 42.8 39.9–45.8 229,773 43.5

Sex

Male . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 634 48.4 45.4–51.3 280,767 53.2

Female . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 745 51.6 48.7–54.6 246,963 46.8

Race and ethnicity

Hispanic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 268 12.4 10.1–15.2 68,008 12.9

Non-Hispanic white . . . . . . . . . . . . . . . . . . . . . . . . . . 850 71.3 67.5–74.9 399,854 75.8

Non-Hispanic black . . . . . . . . . . . . . . . . . . . . . . . . . . 234 14.2 11.9–16.8 49,712 9.4

Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 2.1 1.4–3.1 10,156 1.9

. . . Category not applicable.

1Available from: http://www.cancer-rates.info/naaccr/ [Accessed December 26, 2013].

2Equals 95%.

SOURCE: CDC/NCHS, 1986–2009 National Health Interview Survey linked with 1981–2010 Florida Cancer Data System.

Page 14 [ Series 2, No. 167
Table 5. Cancer stage at diagnosis, by education level, poverty level, marital status, and sex: 1986–2009 Florida National Health Interview

Survey participants aged 18 and over linked with 1981–2010 Florida Cancer Data System after interview

Characteristic

Early stage1 Late stage2

Number

Weighted

percent

Confidence

interval3 Number

Weighted

percent

Confidence

interval3

Overall

Education level:

Less than high school . . . . . . . . . . . . . . . . . . . . . . . 975 92.7 90.6–94.3 77 7.3 5.7–9.4

High school graduate, GED, or some college . . . . . . . . . 2,318 95.2 94.1–96.1 108 4.8 3.9–5.9

Post-high school degree . . . . . . . . . . . . . . . . . . . . . . 802 96.8 95.1–98.0 23 3.2 2.0–4.9

Poverty level:

Below threshold . . . . . . . . . . . . . . . . . . . . . . . . . . . 288 89.5 85.1–92.7 29 10.5 7.3–14.9

Above threshold . . . . . . . . . . . . . . . . . . . . . . . . . . . 3,302 95.5 94.6–96.4 150 4.5 3.7–5.4

Marital status:

Married . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2,800 95.8 94.9–96.6 117 4.2 3.5–5.1

Not married, widowed, or separated. . . . . . . . . . . . . . . 1,311 93.4 91.9–94.6 92 6.6 5.4–8.1

Men

Education level:

Less than high school . . . . . . . . . . . . . . . . . . . . . . . 502 92.0 89.7–93.9 41 8.0 6.2–10.3

High school graduate, GED, or some college . . . . . . . . . 1,061 94.3 92.8–95.5 61 5.7 4.5–7.2

Post-high school degree . . . . . . . . . . . . . . . . . . . . . . 450 96.0 92.9–97.8 15 4.0 2.2–7.2

Poverty level:

Below threshold . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 87.4 81.7–91.5 15 12.6 8.5–18.3

Above threshold . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,667 94.9 93.5–96.1 83 5.1 3.9–6.5

Marital status:

Married . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,565 94.8 93.2–96.0 79 5.2 4.0–6.8

Not married, widowed, or separated. . . . . . . . . . . . . . . 458 92.6 89.9–94.7 37 7.4 5.4–10.1

Women

Education level:

Less than high school . . . . . . . . . . . . . . . . . . . . . . . 473 93.4 90.4–95.5 36 6.6 4.5–9.6

High school graduate, GED, or some college . . . . . . . . . 1,257 96.0 94.8–97.0 47 4.0 3.0–5.2

Post-high school degree . . . . . . . . . . . . . . . . . . . . . . 352 98.0 95.5–99.1 8 *2.0 0.9–4.5

Poverty level:

Below threshold . . . . . . . . . . . . . . . . . . . . . . . . . . . 173 91.0 82.7–95.6 14 *9.0 4.4–17.3

Above threshold . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,635 96.2 95.1–97.0 67 3.8 3.0–4.9

Marital status:

Married . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,235 97.2 96.3–97.8 38 2.9 2.2–3.7

Not married, widowed, or separated. . . . . . . . . . . . . . . 853 93.8 91.8–95.4 55 6.2 4.6–8.3

* Figure does not meet standards of reliability or precision; relative standard error greater than 30%.

1Includes in situ and localized tumors at diagnosis.

2Includes tumors that have spread regionally or to distant sites of the body at diagnosis.

3Equals 95%.

NOTES: Education level was missing for 52 NHIS participants, income data were missing for 676, marital status was missing for 31, and cancer stage was missing for 19. GED is General Educational

Development high school equivalency diploma.

SOURCE: CDC/NCHS, 1986–2009 National Health Interview Survey linked with 1981–2010 Florida Cancer Data System.

Series 2, No. 167 [ Page 15
Table 6. Percentage of smoking status, self-rated health, and any activity limitation, by sex: 1986–2009 Florida National Health Interview

Survey participants aged 18 and over linked with 1981–2010 Florida Cancer Data System before interview (cancer survivor) and not linked

(not diagnosed with cancer)

Characteristic

Cancer survivor Not previously diagnosed with cancer

Number

Weighted

percent

Confidence

interval1 Number

Weighted

percent

Confidence

interval1

Overall

Self-rated health:

Fair or poor. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 669 33.2 30.1–36.6 6,756 13.0 12.4–13.7

Excellent, very good, or good. . . . . . . . . . . . . . . . . . . 1,261 66.8 63.4–70.0 44,020 87.0 86.3–87.6

Any limitation:

Yes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 726 38.1 35.3–41.0 7,863 15.5 14.6–16.3

No . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,213 61.9 59.0–64.7 43,074 84.5 83.7–85.4

Smoking status2

:

Never . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305 43.8 38.5–49.4 7,883 55.7 54.1–57.2

Current . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 10.0 7.9–12.5 3,060 22.5 21.4–23.7

Former. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 312 46.2 41.0–51.4 2,922 21.8 20.8–22.9

Men

Self-rated health:

Fair or poor. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 355 36.0 31.8–40.4 2,713 11.6 10.8–12.4

Excellent, very good, or good. . . . . . . . . . . . . . . . . . . 596 64.0 59.6–68.2 20,445 88.4 87.6–89.2

Any limitation:

Yes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 377 40.1 36.4–43.9 3,383 14.4 13.5–15.5

No . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 577 59.9 56.1–63.6 19,840 85.6 84.5–86.5

Smoking status2

:

Never . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108 32.1 24.2–41.2 3,050 49.7 47.9–51.6

Current . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 10.5 7.4–14.7 1,537 25.0 23.6–26.5

Former. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199 57.4 49.0–65.5 1,578 25.2 23.8–26.8

Women

Self-rated health:

Fair or poor. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 314 30.5 26.8–34.5 4,043 14.3 13.5–15.0

Excellent, very good, or good. . . . . . . . . . . . . . . . . . . 665 69.5 65.6–73.2 23,575 85.8 85.0–86.5

Any limitation:

Yes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 349 36.1 32.0–40.5 4,480 16.4 15.5–17.3

No . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 636 63.9 59.5–68.0 23,234 83.6 82.7–84.5

Smoking status2

:

Never . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197 56.2 50.3–61.9 4,833 61.0 59.0–63.0

Current . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 9.5 7.3–12.2 1,523 20.2 18.9–21.5

Former. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 34.4 28.7–40.5 1,344 18.8 17.4–20.2

1Equals 95%.

2Limited to survey years 1997–2009.

SOURCE: CDC/NCHS, 1986–2009 National Health Interview Survey linked with 1981–2010 Florida Cancer Data System.

Page 16 [ Series 2, No. 167
Vital and Health Statistics

Series Descriptions

ACTIVE SERIES

Series 1. Programs and Collection Procedures—This type of report

describes the data collection programs of the National Center

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other material necessary for understanding the data.

Series 2. Data Evaluation and Methods Research—This type of

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techniques, objective evaluations of reliability of collected

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Series 13. Data From the National Health Care Survey—This type of

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