Transcript Slide 1

Understanding the Colorectal Cancer Burden in Kentucky:
Environmental, Behavioral and Genetic Risk Factors
Presented by:
Thomas C. Tucker, PhD, 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
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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.
Most Common Cancer Control Sites
58% of Total Cancer Cases in the U.S.
All genders, All races, 2004-2008
Prostate
15%
Lung and
Bronchus
14%
Other
42%
Female
Breast
14%
Cervix
1%
Melanoma
4%
Colon and Rectum
10%
Most Common Cancer Control Sites
61% of Total Cancer Cases in Kentucky
All genders, All races, 2004-2008
Prostate
11%
Lung and
Bronchus
18%
Other
39%
Female
Breast
14%
Cervix
Melanoma
1%
6%
Colon and Rectum
11%
Most Common Cancer Control Sites
52% of Total Cancer Deaths in the U.S.
All genders, All races, 2004-2008
Prostate
5%
Lung and
Bronchus
28%
Other
48%
Female Breast
7%
Cervix
1%
Colon and Rectum
9%
Melanoma
2%
Most Common Cancer Control Sites
58% of Total Cancer Mortality in Kentucky
All genders, All races, 2004-2008
Prostate
4%
Lung and
Bronchus
36%
Other
42%
Female Breast
6%
Cervix
1% Melanoma
2%
Colon and Rectum
9%
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)
Geographic Area Both Genders
United States
Kentucky
Males
Females
46.2
(46.1-46.3)
53.8
(53.6-53.9)
40.2
(40.0-40.3)
55.1
(54.1-56.1)
65.7
(64.0-67.3)
46.9
(45.7-48.1)
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)
Geographic Area Both Genders
United States
Kentucky
Males
Females
16.7
(16.6-16.8)
20.2
(20.0-20.3)
14.1
(14.0-14.2)
19.8
(19.3-20.4)
24.3
(23.3-25.3)
16.6
(15.9-17.3)
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)
Geographic Area
All Races
White
Black
United States
46.2
(46.1-46.3)
45.1
(45.0-45.2)
54.8
(54.4-55.2)
55.1
(54.1-56.1)
54.6
(53.6-55.6)
64.3
(59.9-69.0)
Kentucky
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)
Geographic Area
All Races
White
Black
United States
16.7
(16.6-16.8)
16.2
(16.1-16.2)
23.7
(23.4-23.9)
19.8
(19.3-20.4)
19.5
(18.9-20.1)
27.7
(24.8-30.9)
Kentucky
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.
Colorectal Cancer Incidence (2000-2009)
Colorectal Cancer Incidence Rate
Линейная (Colorectal Cancer
Incidence Rate)
90
R² = 0,97
Colorectal Cancer Incidence Rate
85
80
75
70
65
60
55
50
45
1999
2000
2001
2002
2003
2004
2005
Year
2006
2007
2008
2009
2010
Colorectal Cancer Incidence (2000-2009)
Males
Females
Линейная (Males)
90
Colorectal Cancer Incidence Rate
85
80
R² = 0,8506
75
70
65
60
R² = 0,9047
55
50
45
1999
2000
2001
2002
2003
2004
2005
Year
2006
2007
2008
2009
2010
Colorectal Cancer Incidence (2000-2009)
Black Males
White Females
Линейная (Black Females)
100
95
White Males
Линейная (Black Males)
Линейная (White Females)
Black Females
Линейная (White Males)
Black Males
Colorectal Cancer Incidence Rate
90
R² = 0,2231
85
White Males
80
Black Females
R² = 0,8505
75
70
65
60
R² = 0,6904
White Females
R² = 0,9117
55
50
45
1999
2000
2001
2002
2003
2004
2005
Year
2006
2007
2008
2009
2010
Colorectal Cancer Incidence (2000-2009)
Urban Males
Rural Females
90
Colorectal Cancer Incidence Rate
85
Rural Males
Линейная (Urban Males)
Urban Males
Urban Females
Линейная (Rural Males)
R² = 0,9396
80
75
Rural Males
R² = 0,1501
70
65
Urban Females
R² = 0,8948
60
55
Rural Females
R² = 0,6755
50
45
1999
2000
2001
2002
2003
2004
2005
Year
2006
2007
2008
2009
2010
Colorectal Cancer Incidence (2000-2009)
90
85
Non-Appalachian Males
Appalachian Males
Appalachian Females
Non-Appalachian Females
Линейная (Non-Appalachian Males)
Линейная (Appalachian Males)
Линейная (Appalachian Females)
Линейная (Non-Appalachian Females)
Non-Appalachian Males
Colorectal Cancer Incidence Rate
R² = 0,8659
80
75
Appalachian Males
R² = 0,1432
70
65
Appalachian Females
R² = 0,5709
60
55
Non-Appalachian Females
50
R² = 0,8898
45
1999
2000
2001
2002
2003
2004
2005
Year
2006
2007
2008
2009
2010
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
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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
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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
College Education vs. Screening Rate
Colonoscopy & Sigmoidoscopy
75
65
R² = 0,3514
55
Screening vs Education
Линейная (Screening vs
Education)
45
10
15
20
25
30
35
College Education
40
45
50
55
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
%
Rank
Rate
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
53.8
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
21.0
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
54.4
54.9
Rank
15
32
43
40
7
9
Rate
51.9
41.9
47.5
43.6
38.9
40.6
Rank
9
41
20
35
47
45
Rate
16.0
20.2
20.3
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
111
113
114
117
119
121
124
125
130
133
142
143
143
144
145
149
153
154
154
157
161
165
170
Colorectal Cancer by Area Development District in KY, 2005-2009
High
Area
School
Development Education
District
(%)
2006-2010
U.S.
Kentucky
Barren River
Big Sandy
Bluegrass
Buffalo Trace
Cumberland
Valley
Fivco
Gateway
Green River
Kentucky
River
Kipda
Lake
Cumberland
Lincoln Trail
Northern
Kentucky
Pennyrile
Purchase
Colorectal Age-Adjusted
Age-Adjusted
Poverty
Cancer
Incidence
Late Stage
Mortality
Rate (%)
Screening
Incidence
2006Rate (%) Number Rate
%
Number Rate
2010
2006-2010
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
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
65.6
29.2
50.8
440
68.4
56.2
140
22.5
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
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
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
High School
Area
Development
District
Current
Age-
Age-
EducationCancer
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
Percent
Rank
Rate
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
86.4
84.7
1
3
2
6
5
8
4
7
11
9
10
12
15
14
13
35.7
35.5
35.5
32.0
33.0
31.8
31.1
32.5
30.3
31.3
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 49th 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
49th
in the U.S.
2002
2004
2006
2008
2010
20th
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.
Colorectal Cancer Incidence, Kentucky
(1999-2009)
75
70
68,22
Incidence
68,81
66,69
65,41 65,2
65
64,14
61,14
59,35
60
59,5
58,01
57,02
Rate
53,76
55
50
45
40
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Year
P<.05
Source: http://cancer-rates.info/ky, Accessed May, 2013
Colorectal Cancer Mortality, Kentucky
(1999-2009)
25
24,24
23,61
24
23
22,63
22,51
23,02
Mortality
22
21
20,48
20,63
20,5
19,58
Rate 20
19,13
19
18
18,96
17,45
17
16
15
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Year
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
PhD, MPH
[email protected]
End
The Kentucky Cancer Registry acknowledges the Centers
for Disease Control and Prevention for its support under
cooperative agreement U58DP000810 and the National
Cancer Institute for its support under contract number
N01PC-2010-00031.