What does the data tell us? Colorectal CANCER IN NEVADA Paulo S Pinheiro University Nevada Las Vegas, Roseman SM 2016

Aims To analyze Nevada Central Cancer Registry (NCCR) and BRFSS data for prevalence of screening, 2014 Screening Incidence, Mortality Survival TO Use SEER data to represent the US in the survival analysis To identify issues specific to Nevada, with an emphasis on priorities for intervention

Nevada: How does Colorectal Cancer affect the state? Nevada: 2.9 million Dynamic demographics doubled its population in the past 20 years Highest proportion of undocumented in the Nation (8% of all population) Diverse mix of people (race- ethnicity, long-term residents, recent arrivals) difficult to characterize risk patterns

Evidence-Based Action in Nevada Nevada Central Cancer Registry Incidence and survival indicators General measures: all states Evidence-based measures: Nevada-specific How does Nevada differ from other states?

Levels of Prevention Legislation on cancer prevention ↓incidence Access to prevention care ↓ incidence Access to quality tertiary care –↑survival, ↓mortality Screening: ↓mortality ↓incidence ↑overall survival

SCREENING Lowers incidence (risk) Increases overall survival Lowers mortality

Sigmoidoscopy/Colonoscopy in Nevada 2015 Demographic Grouping N Weighted N Yes Statewide Nevada 1,688 762,113 64.1 (60.2-68.1) Geography Clark County 501 492,912 61.4 (55.6-67.1) Northwestern NV 906 205,113 73.4 (69.6-77.2) Balance of State 281 64,087 56.1 (48.8-63.3) Race/Ethnicity White 1,375 625,299 66.1 (62.8-69.4) Black 52 63,212 67.8 (53.4-82.1) Other Race 117 95,304 47.4 (32.3-62.6) Hispanic 109 106,756 53.5 (41.3-65.7) Education Less than H.S. 141 101,318 45.4 (32.8-58.1) H.S. or G.E.D. 581 261,736 55.6 (49.4-61.9) Some Post H.S. 783 337,734 65.6 (60.6-70.6) College Graduate 772 199,073 78.5 (73.7-83.3) Income < 15,000 179 83,684 50.8 (37.7-63.9) $15,000 to $24,999 344 126,251 55.5 (47.3-63.8) $25,000 to $34,999 239 110,486 59.5 (48.1-71.0) $35,000 to $49,999 322 123,273 59.3 (50.2-68.3) $50,000 to $74,999 126,919 69.6 (61.7-77.6) $75,000+ 552 213,227 70.7 (64.5-76.9) Source: Nevada State Health Division, B Towle Aug 2016 BRFSS

Comparison: High-Screening States vs Nevada Connecticut Utah Nevada Combined Screening 76% VERY HIGH 75% 64% LOWER AJCC STAGE DISTRIBUTION (%) I 26 21 II 24 25 III 28 31 IV 23 22 MORTALITY RATE (per 100,000) 11.8 11.0 16.9 Source: Nevada Central Cancer Registry and SEER

Nevada CRC Raw Numbers 1140 per year 482 per year New Cases Deaths Source: CDC wonder

Colorectal Cancer Incidence 2008-2010 Men 50.6 (US 50.3) Women 36.3 (US 38.1) 24 40 51 51 33 36 49 49 Source: CDC wonder

Colorectal Cancer Mortality 2011-2013 Men 19.9 (US 17.7) Women 14.2 (US 12.4) 10 8 51 51 41 38 47 43 Source: CDC wonder

Incidence And Mortality Ranks For Nevada Males: #24 for Incidence but #10 for Mortality Females: #40 for Incidence but #8 for Mortality Anything strange with this?

Deaths Per Year in Nevada, 2013 Leading Cancers Men and Women Men Women All Cancers 4,817 2,609 2,208 LUNG 1,335 719 616 COLORECTAL 482 264 218 BREAST 352 - PANCREAS 325 167 158 PROSTATE 278 LEUKEMIA 196 132 64 LIVER 182 131 51 BLADDER 139 107 32 MELANOMA 68 49 19 Source: CDC wonder

CRC – If Nevada was just average Of the 482 annual deaths in the state, we could save 57 every year

NV MORTALITY RANK: Colorectal CANCER 2011-2013 (out of 51) Men Women ALL RACES 10 8 Whites 4* 1* Blacks 42 40 Hispanics 32 29 Asians 19 17 *Significantly higher than US average p<0.05 Source: CDC Wonder

SURVIVAL

Data from SEER and NCCR Diagnoses: 2003-2013 Age-adjustment by ICCC standards Follow-up until Dec 31, 2013 Presumed-Alive assumption N=10,076 first primaries of CRC in Nevada Cause-specific survival Nevada data: no National Linkage Life Tables Method and Cox Regression

SURVIVAL BY AJCC STAGE AT DIAGNOSIS MEN WOMEN

SURVIVAL BY REGION

Risk of Death Colorectal Cancer Nevada 2003-2013 Cox Proportional Hazards Model HR* (95% CI) AJCC Stage I 1,711 1 II 2,047 2.2 1.8-2.7 III 2,407 4.0 3.3-4.8 IV 1,766 14.5 12.1-17.5 Race/Ethnicity: NH-White 7,495 NH-Black 737 0.88 0.76-1.01 Hispanic 928 0.83 0.73-0.95 Asian Pacific Islander 618 0.77 0.62-0.95 American Indian 66 0.92 0.54-1.56 Region: North – Reno 2,304 South – Las Vegas 7,038 1.12 1.02-1.22 Rural 734 0.98 0.84-1.15 *Adjusted for age, gender, year of diagnosis, sublocation (right colon, sigmoid, rectum, NOS) , grade of tumor, insurance type, SES

Reasons for North-South Gap? Lower screening in South 2015, 61% VS 73% Low Number of general & family practice physicians 22 vs 31 (US) per 100,000 Low Number of Medical Doctors 216 vs 327 (US) per 100,000 Washoe at 336 per 100,000 Clark County: only 65% of the US average number of physical specialists Lack of a LV-based MD School of Medicine: research activity, teaching status, clinical trials, etc.

Treatment for Colorectal Cancer Stage Treatment POLIPECTOMY (during colonoscopy) I SURGERY II SURGERY with/without ADJUVANT CHEMOTHERAPY, RADIOTHERAPY (for rectal cancer) III SURGERY with ADJUVANT CHEMOTHERAPY, and RADIOTHERAPY (for rectal cancer) IV COMBINATIONS (SURGERY, CHEMO, RADIO) Source: cancer.net ASCO

Conclusions 1-Incidence in NV (risk) is average 2-Mortality in NV is high 3-Unfavorable stage distribution, lower rates of screening, low survival by stage in Clark County drive the state’s numbers FOCUS: i)-Increase Screening (will affect stage distribution) ii)-Improve Quality of Care (will improve survival)

paulo.pinheiro@unlv.edu 702-895-5717 THANK YOU