Understanding the Colorectal Cancer Burden in Kentucky Environmental

Understanding the Colorectal Cancer Burden in Kentucky: Environmental, Behavioral and Genetic Risk Factors Presented by: Thomas C. Tucker, Ph. D, MPH Director Kentucky Cancer Registry Senior Director for cancer Surveillance Associate Director for Cancer Control Markey Cancer Center University of Kentucky Colon Cancer Forum Knicely Conference Center Bowling Green, KY – Oct. 3, 2013

Topics to be covered • • • Factors that contribute to the onset of colorectal cancer. Colorectal cancer as a % of all cancers incidence cases and deaths. Colorectal cancer in Kentucky compared to the U. S. Ranking states by colorectal cancer incidence and mortality rates. Trends in Kentucky colorectal cancer incidence. More precisely defining the colorectal cancer burden in Kentucky. Sources of data available for defining the colorectal cancer burden. Combining data to better describe the burden of colorectal cancer. A model for cancer control. An example of using colorectal cancer incidence data in combination with other data sources to focus limited resources and measure the impact of interventions.

Factors that contribute to the onset of cancer.

Factors Contributing to the Onset of Cancer Lifestyle Interactions Environmental Occupational Family History Genetics

Components Contributing to the Onset of Cancer Lifestyle Factors (68%) Occupational and Environmental Exposures (18%) Genetics and Family History (13%) Source: Harvard Report on Cancer Prevention, Cancer Causes & Control, Vol. 7, Supplement 1, Nov. 1996

It is important to note that the relative contribution of environmental, genetic, and behavioral factors will be different for each specific type of cancer and in each individual. It is also important to note that the interaction between environmental, genetic, and behavioral factors may significantly increase the risk of cancer.

Factors Contributing to the Onset of Cancer Lifestyle (68%) Interactions Environmental Occupational (18%) Family History Genetics (13%)

Colorectal cancer as a % of all cancers incidence cases and deaths.

Comparing colorectal cancer incidence and mortality in Kentucky to the U. S.

Colorectal Cancer Incidence Rates in the U. S. Compared to Kentucky (2005 -2009) Rates per 100, 000 persons and age-adjusted to the 2000 U. S. standard population

Colorectal Cancer Mortality Rates in the U. S. Compared to Kentucky (2005 -2009) Rates per 100, 000 persons and age-adjusted to the 2000 U. S. standard population

Colorectal Cancer Incidence Rates in the U. S. Compared to Kentucky (2005 -2009) Rates per 100, 000 persons and age-adjusted to the 2000 U. S. standard population

Colorectal Cancer Mortality Rates in the U. S. Compared to Kentucky (2005 -2009) Rates per 100, 000 persons and age-adjusted to the 2000 U. S. standard population

States ranked by colorectal cancer incidence and mortality rates.

Both Genders, Colorectal Cancer Incidence Rates Ranked by State (2005 – 2009)

Both Genders, Colorectal Cancer Mortality Rates Ranked by State (2005 – 2009)

Trends in Kentucky colorectal cancer incidence and mortality rates.

Combining Data from Multiple Sources Demographic Characteristics Contribute to Risk Factors Contribute to Incidence and Late Stage DX Contribute to Cancer Mortality Logic Model

Common sources of data that can be used for defining the cancer burden • • Demographic data (Census U. S) Risk factor data (BRFSS) Incidence data (KCR) Mortality data (State Vital Records)

Demographic (U. S. Census) data • Covers the entire population • Provides details on important factors that influence the burden of cancer in a population • Is only done once every 10 years in the U. S. • Is difficult to determine the number of people in a population by race and ethnicity.

CDC’s Behavioral Risk Factor Surveillance System • • Largest telephone survey in the world Tracks many important health risks Complex sample design Difficult to generalize the information to small populations

Incidence Data • Closer in time to causal events • Represents both occurrence and risk of getting disease • Difficult to get all of the cases • Complex coding rules • Screening effect

Mortality Data • Very complete data • Represents the ultimate negative health outcome • Far away in time from causal factors • Care must be taken to use consolidated death records

The C-Change Project Objectives • Build a separate index for the burden of lung, breast, and colorectal cancer. • Construct the index using demographic data from the U. S. Census; risk factor data from the BRFSS; and incidence, stage at diagnosis, and mortality data from the NAACCR CINA data file. • Use the index to identify the states with the highest disease burden for lung, breast, and colorectal cancer.

Methodology (Approach) • The association between the demographic, risk, incidence, stage at diagnosis and mortality variables were explored using bivariate regression models. • Variables with R-Squared values. 25 or greater were used to construct the initial index for each type of cancer. • The index was created using a simple rank sum technique. States were ranked from the highest to lowest cancer burden and placed into five groups with red being the states with the highest burden of cancer and green being those states with the lowest cancer burden. Highest Burden Lowest Burden

Colorectal Cancer

Colorectal Cancer Rank for States 2008 -09 State Mississippi Louisiana West Virginia Kentucky Arkansas Oklahoma Alabama Indiana Nebraska Nevada Ohio Illinois Tennessee Pennsylvania Alaska Iowa Missouri North Dakota Wyoming South Dakota New Jersey Texas Montana College Ed+ Colonoscopy Incidence Mortality % Rank Rate 19. 5 20. 9 17. 3 20. 3 19. 1 22. 6 21. 7 22. 4 27. 7 21. 8 24. 1 30. 3 22. 7 26. 4 27. 0 24. 5 25. 0 26. 3 23. 6 25. 3 34. 6 25. 8 27. 9 3 5 1 4 2 9 6 8 31 7 13 37 10 26 28 15 17 25 11 18 44 20 32 53. 5 51. 2 54. 1 61. 4 54. 0 53. 5 57. 1 57. 9 55. 1 55. 5 59. 0 57. 4 57. 9 60. 7 56. 6 59. 8 59. 6 57. 2 54. 4 59. 3 58. 5 56. 2 54. 8 2 1 5 30 4 3 14 18 10 11 22 17 19 29 13 27 24 16 6 23 21 12 8 53. 6 52. 4 57. 1 45. 4 48. 0 52. 1 49. 1 50. 7 45. 1 47. 6 52. 6 47. 3 53. 2 52. 3 51. 2 49. 1 51. 5 41. 9 47. 0 49. 4 43. 5 45. 5 2 3 6 1 26 16 8 14 12 27 18 5 21 4 7 11 15 10 40 22 13 36 25 24. 7 23. 7 22. 4 23. 5 22. 0 21. 6 21. 5 21. 8 22. 2 21. 5 21. 8 22. 0 21. 7 20. 1 20. 6 20. 8 19. 7 19. 5 20. 2 21. 9 19. 2 18. 3 Rank 1 3 5 4 8 13 15 10 6 14 11 7 17 12 24 19 18 26 27 23 9 31 37 Overall Index 8 12 17 39 40 41 43 50 59 59 64 66 67 71 72 72 74 77 84 86 87 99 102

Colorectal Cancer Rank for States 2008 -09 State College Ed+ Colonoscopy Incidence Mortality Hawaii South Carolina Maine Michigan New Mexico Idaho % 29. 4 24. 0 26. 5 25. 0 25. 5 24. 3 Rank 34 12 27 16 19 14 % 57. 2 62. 6 68. 5 67. 4 54. 9 Rank 15 32 43 40 7 9 Rate 51. 9 47. 5 43. 6 38. 9 40. 6 Rank 9 41 20 35 47 45 Rate 16. 0 20. 2 20. 3 17. 9 16. 9 Rank 48 22 21 20 40 46 Georgia North Carolina Washington DC Florida New York California Delaware Wisconsin New Hampshire Oregon Arizona Maryland Massachusetts Connecticut Rhode Island Virginia Minnesota Colorado Washington Utah 27. 2 26. 1 49. 2 25. 9 32. 1 30. 1 27. 7 25. 8 32. 9 28. 6 26. 3 35. 7 38. 3 35. 2 30. 3 33. 8 31. 4 35. 9 31. 0 29. 4 29 23 49 22 41 36 30 21 42 33 24 46 48 45 38 43 40 47 39 35 59. 7 64. 3 66. 7 61. 6 64. 8 58. 5 71. 4 65. 7 67. 9 63. 8 60. 4 69. 1 68. 9 69. 1 69. 3 67. 6 69. 6 59. 6 65. 0 65. 1 26 34 39 31 35 20 49 38 42 33 28 45 44 46 47 41 48 25 36 37 44. 6 44. 9 44. 8 43. 4 47. 6 44. 6 45. 0 40. 7 46. 3 42. 2 36. 0 43. 2 46. 1 47. 9 44. 6 41. 9 45. 1 40. 0 41. 8 34. 2 33 30 31 37 19 32 29 44 23 39 48 38 24 17 34 42 28 46 43 49 19. 5 18. 9 24. 3 18. 6 19. 4 17. 7 19. 9 18. 2 18. 5 18. 3 17. 1 21. 2 18. 8 17. 0 18. 5 19. 5 17. 8 17. 5 16. 6 14. 5 29 32 2 34 30 42 25 39 36 38 44 16 33 45 35 28 41 43 47 49 Overall Index 106 107 111 113 114 117 119 121 124 125 130 133 142 143 144 145 149 153 154 157 161 165 170

Colorectal Cancer by Area Development District in KY, 2005 -2009 Age-Adjusted Colorectal Age-Adjusted High School Poverty Incidence Mortality Cancer Area Late Stage Education Rate (%) Development Screening Incidence (%) 2006 Number Rate District Rate (%) Number Rate % 2006 -2010 U. S. Kentucky Barren River Big Sandy Bluegrass Buffalo Trace Cumberland Valley Fivco Gateway Green River 87. 6 81. 0 78. 6 69. 0 84. 7 73. 3 15. 1 17. 4 19. 1 25. 2 16. 9 22. 4 62. 2 56. 0 55. 7 67. 3 54. 5 13373 863 598 2027 217 58. 8 59. 0 68. 8 54. 5 65. 9 51. 4 57. 1 52. 3 49. 9 54. 4 4410 286 178 683 75 19. 6 21. 2 18. 7 23. 1 67. 8 28. 7 54. 4 756 57. 7 51. 7 286 22. 2 78. 2 73. 7 83. 0 19. 5 25. 2 15. 5 60. 0 55. 8 62. 7 525 281 646 62. 8 66. 8 53. 1 49. 5 55. 0 53. 8 157 98 207 19. 3 23. 5 16. 9 Kentucky River 65. 6 29. 2 50. 8 440 68. 4 56. 2 140 22. 5 Kipda Lake Cumberland Lincoln Trail Northern Kentucky Pennyrile Purchase 86. 4 14. 3 67. 3 2926 60. 0 49. 2 958 19. 8 70. 9 24. 3 55. 5 706 57. 1 52. 8 221 17. 9 82. 7 14. 8 59. 6 839 63. 3 53. 1 270 21. 0 86. 4 11. 4 64. 6 1169 58. 4 52. 3 413 21. 2 80. 1 83. 0 18. 5 16. 3 57. 6 66. 8 710 670 57. 3 53. 7 51. 7 44. 7 219 17. 8 16. 9

Colorectal Cancer by Area Development District in KY, 2005 -2009 Area Development District High School Education, 20062010 Colorectal Cancer Screening, 2006 -2010 Percent Rank Kentucky River 65. 6 1 50. 8 Buffalo Trace 73. 3 5 Gateway Cumberland Valley Lake Cumberland 73. 7 Late Stage Incidence Overall Rank Rate Rank 1 56. 2 2 4 54. 5 3 54. 4 4 12 6 55. 8 6 55. 0 3 15 67. 8 2 54. 4 2 51. 7 11 15 70. 9 4 55. 5 4 52. 8 7 15 Barren River 78. 6 8 56. 0 7 57. 1 1 16 Big Sandy 69. 0 3 55. 7 5 52. 3 8 16 Lincoln Trail 82. 7 10 59. 6 9 53. 1 6 25 Pennyrile 80. 1 9 57. 6 8 51. 7 10 27 Green River 83. 0 11 62. 7 11 53. 8 5 27 Fivco Northern Kentucky Bluegrass 78. 2 7 60. 0 10 49. 5 13 30 86. 4 15 64. 6 12 52. 3 9 36 84. 7 13 67. 3 14 49. 9 12 39 Purchase 83. 0 12 66. 8 13 44. 7 15 40 Kipda 86. 4 14 67. 3 15 49. 2 14 43

Unique KY Resources for Cancer Control Kentucky Cancer Consortium (KCC) Kentucky Cancer Program (KCP) Lung Cancer by Area Development District in KY, 2005 -2009 Area Development District High School Current Age- Education. Cancer Smokers Adjusted Kentucky Registry (KCR) Adjusted 2006 -2010 2001 -2005 Incidence Mortality Kentucky River Big Sandy Cumberland Valley Gateway Buffalo Trace Barren River Lake Cumberland Fivco Green River Pennyrile Lincoln Trail Purchase Northern Kentucky Kipda Bluegrass Percent Rank Rate Rank 65. 6 69. 0 67. 8 73. 7 73. 3 78. 6 70. 9 78. 2 83. 0 80. 1 82. 7 83. 0 86. 4 84. 7 1 3 2 6 5 8 4 7 11 9 10 12 15 14 13 35. 7 35. 5 32. 0 33. 0 31. 8 31. 1 32. 5 30. 3 31. 1 28. 5 29. 0 28. 6 28. 2 1 2 3 6 4 7 10 5 11 8 9 14 12 13 15 124. 7 131. 7 117. 2 102. 1 96. 9 105. 8 101. 2 99. 9 105. 0 97. 2 96. 3 97. 7 96. 2 94. 9 92. 6 2 1 3 6 11 4 7 8 5 10 12 9 13 14 15 99. 8 96. 2 86. 0 79. 9 78. 3 78. 0 77. 7 71. 0 76. 1 70. 1 66. 4 69. 4 71. 4 66. 6 68. 0 1 2 3 4 5 6 7 10 8 11 15 12 9 14 13 Overall Rank 5 8 11 22 25 25 28 30 35 38 46 47 49 55 56

An Example In 2001, Kentucky had the highest colorectal cancer incidence rate in the U. S. compared to all of the other states

In 2001, it was also noted that Kentucky was ranked 49 th in colorectal cancer screening compared to all other states with the second to the lowest rate (34. 7% of the age eligible population).

Data about the burden of colorectal cancer was assembled and presented to each of the 15 District Cancer Councils. Following these presentations, all 15 of the District Cancer Councils implemented evidence-based cancer control programs aimed at increasing colorectal cancer screening for age eligible people living in their District. What happened following the implementation of these colorectal cancer screening programs?

Colorectal Cancer Screening in Kentucky 70% 63. 7% 58. 6% 60% 50% 40% 30% 63. 7% 43. 9% 47. 2% 34. 7% 1999 49 th in the U. S. 2002 2004 2006 2008 2010 20 th in the U. S.

The increase in colorectal cancer screening has been accompanied by a 22% decrease in both the incidence and mortality of colorectal cancer in Kentucky. It is important to note that these changes are statistically significant (P<. 05). In other words, it is unlikely that these changes happened by random accident.

P<. 05 Source: http: //cancer-rates. info/ky, Accessed May, 2013

P<. 05 Source: http: //cancer-rates. info/ky, Accessed May, 2013

A 22% reduction in colorectal cancer incidence and mortality in Kentucky is a significant public health success. Working together we can make a real difference in peoples lives.

Relationship between Areas with High Arsenic Levels and High Colorectal Cancer Incidence Rates in Kentucky Arsenic and colorectal cancer incidence rates. (Top) Arsenic content and coal field locations in Kentucky; (Bottom) Incidence of colorectal cancer in the Appalachian versus Non-Appalachian region of Kentucky.

Thank You! Contact Information: Thomas C. Tucker, Questions Ph. D, MPH tct@kcr. uky. edu. The End The Kentucky Cancer Registry acknowledges the Centers for Disease Control and Prevention for its support under cooperative agreement U 58 DP 000810 and the National Cancer Institute for its support under contract number N 01 PC-2010 -00031.