(2) - Department of Epidemiology and Population Health, and Lead Time between Diagnosis and Treatment of Cancer in Kentucky, 1995-2005 F. D. Groves 1,2 and R.C. Gupta 1,3 - Brown Cancer Center, (2) - Department of Epidemiology and Population Health, and (3) - Department of Pharmacology and Toxicology, University of Louisville

BACKGROUND: “Chemoprevention” of cancer using nutritional supplements or “nutraceuticals” is an appealing concept that has not proven effective to date Why not provide nutritional supplementation or “nutraceuticals” to newly-diagnosed cancer patients while they are waiting for treatment? This is the United States of America – NOBODY waits for treatment … … or do they?

BACKGROUND: Treatment of most forms of cancer should be initiated within four to eight weeks of diagnosis Longer lead times have been documented in the literature, at least in Canada and the United Kingdom Here we report the lead times between diagnosis and treatment of several forms of cancer in Kentucky Racial and regional differences were investigated Data from University of Louisville Hospital and Clinics will be compared with the state as a whole

METHODS : Data on Kentucky residents diagnosed with breast, cervical, colorectal, lung, and prostate cancers during 1995-2005 were obtained from the Kentucky Cancer Registry UofL data came from the hospital-based registry Time–to-treatment was modeled by Cox proportional hazards regression as a function of race (white, black, other, and unknown) and also, among whites, stratified by usual place of residence (among the fifteen Area Development Districts).

METHODS: Hazard ratios and 95% confidence intervals were calculated for time-to-treatment, censoring those who died at the date of death and those who were lost to follow-up prior to treatment at the date of last contact. Whites residing in the Kentucky-Indiana Planning and Development Area (KIPDA), a seven-county region which includes metro Louisville, were the referent group against which persons of other races, and Whites who resided in other districts, were compared.

RESULTS (Kentucky): In the KIPDA region, the proportion of patients remaining untreated after four weeks of follow-up was… … less than 15% of women with breast cancer … less than 15% of both men and women with colorectal cancer … 26.4% of women with cervical cancer … 35.8% of men and 37.3% of women with lung cancer; and … 61.3% of men with prostate cancer

RESULTS (Kentucky): Racial disparities were obvious, with Blacks having a longer lead time between diagnosis and treatment for every site under consideration. Time-to-treatment was almost always longer among Blacks than among KIPDA Whites, with hazard ratios ranging from 0.763 for Black males with lung cancer to 0.907 for Black males with prostate cancer.

RESULTS (Kentucky): Lead times between diagnosis and treatment were generally equal or shorter among Whites residing in the KIPDA region compared to Whites who resided in other districts Exceptions included the following… … women with breast cancer in the Lake Cumberland District (HR=1.095; 95% CI=1.020-1.175) or in the Purchase district (HR=1.329; 95% CI=1.244-1.420) … women with colorectal cancer in the Purchase district (HR=1.109; 95% CI=1.004-1.227) … men with prostate cancer in the Green River District (HR=1.139; 95% CI=1.060-1.222).

RESULTS (UofL, 2003-7): The proportion of patients diagnosed elsewhere and eventually treated at UofL after waiting more than four weeks was … … approximately 80% of men with prostate cancer ; and … approximately 45% of both men and women with lung cancer The proportion of patients diagnosed at UofL and eventually treated at UofL after waiting more than four weeks was … … approximately 50% of women with breast cancer; and … less than 25% of both men and women with colorectal cancer Only a small fraction of the patients diagnosed at UofL were ever treated elsewhere

IMPLICATIONS: The “lead time” between diagnosis and treatment for three of the “big four” cancers (lung, breast, and prostate) may be sufficient to allow for trials of nutritional supplements and nutraceuticals in the neo-adjuvant setting (i.e., prior to definitive treatment) Why not also offer nutritional and nutraceutical interventions to cancer survivors in the adjuvant setting (i.e., after presumptively curative treatment)? To this end, we have also examined time to recurrence after presumptively curative treatment of cervical, breast, colorectal, lung, and prostate cancer …

Racial Differences in Recurrence- Free Cervical Cancer Survival in Kentucky, 1995-2005 N. Das 1,2, F. D. Groves 1,2, and R.C. Gupta 1,3 - Brown Cancer Center, (2) - Department of Epidemiology and Population Health, and (3) - Department of Pharmacology and Toxicology, University of Louisville

CERVICAL CANCER A total of 3,236 women were diagnosed with cervical cancer and reported to the Kentucky Cancer Registry during 1995-2005; 1,799 of these women (1,643 White, 132 African-American, and 24 others) were known to have remained disease free for at least a week after initial treatment. Time-to-recurrence was modeled using the Cox proportional-hazards method (SAS PROC PHREG).

CERVICAL CANCER The risk of recurrence increased with age at diagnosis (Hazard Ratio [HR] =1.03 per year, 95% confidence interval, [CI] =1.02-1.04). African-American women had slightly but non-significantly elevated age-adjusted recurrence risks after follow-up for … 18 months (9.09% versus 4.81%; Hazard Ratio [HR] =1.76, 95% confidence interval, [CI] =0.96-3.25) … five years (9.85% versus 7.85%; HR=1.16; 95% CI =0.65- 2.05) … ten years (9.85% versus 8.46%; HR=1.07, 95% CI= 0.60- 1.89).

IMPLICATIONS Previous studies of racial disparities in cervical cancer survival have implicated differences in smoking and stage at diagnosis; future studies will adjust for these covariates.

by the Agnes Brown Duggan Endowment. ACKNOWLEDGEMENT Nandita Das’s work was supported, in part, by the Agnes Brown Duggan Endowment.

BREAST CANCER A total of 33,723 women were diagnosed with breast cancer and reported to the Kentucky Cancer Registry during 1995-2005; 21,463 of these women (20,215 White, 1,248 African-American) were known to have remained disease-free for at least a week after initial treatment. Time-to-recurrence was modeled using the Cox proportional-hazards method (SAS PROC PHREG).

BREAST CANCER The risk of recurrence decreased with age at diagnosis (Hazard Ratio [HR] =0.985 per year, 95% confidence interval, [CI] =0.981-0.989). African-American women had statistically significantly elevated age-adjusted recurrence risks after follow-up for … 18 months: (5.36% versus 2.79%; HR=1.88, 95% CI = 1.46-2.43) … five years: (10.50% versus 6.98%; HR=1.52; 95% CI =1.27- 1.81) … ten years: (11.78% versus 8.20%; HR=1.47, 95% CI = 1.24- 1.74).

IMPLICATIONS The substantial racial disparities in recurrence-free breast cancer survival in Kentucky point the way to future trials of both neo-adjuvant and adjuvant nutritional and nutraceutical interventions (“NANNI”).

PROSTATE CANCER A total of 28, 394 men were diagnosed with prostate cancer and reported to the Kentucky Cancer Registry during 1995-2005; 8,415 of these men (7,747 White, 668 African-American) were known to have remained disease-free for at least a week after initial treatment. Recurrence rates after ten years were 4.80% among whites and 5.54% among blacks, with no racial disparity; the risk of recurrence increased with age (HR=1.03; 95% CI=1.02-1.04).

MALE COLON CANCER A total of 10, 738 men were diagnosed with colorectal cancer and reported to the Kentucky Cancer Registry during 1995-2005. 6,100 of these men (5,778 White, 322 African-American) were known to have remained disease-free for at least a week after initial treatment. Recurrence rates after ten years were 12.20% among whites and 13.98% among blacks, with no racial disparity, and no effect of age at diagnosis.

FEMALE COLON CANCER A total of 11, 440 women were diagnosed with colorectal cancer and reported to the Kentucky Cancer Registry during 1995-2005. 6,811 of these women (6,360 White, 451 African-American) were known to have remained disease-free for at least a week after initial treatment. Recurrence rates after ten years were 11.67% among whites and 14.19% among blacks, with no racial disparity, and no effect of age at diagnosis.

MALE LUNG CANCER A total of 21, 735 men were diagnosed with lung cancer and reported to the Kentucky Cancer Registry during 1995-2005. 2,712 of these men (2,613 White, 108 African-American) were known to have remained disease-free for at least a week after initial treatment. Recurrence rates after ten years were 28.24% among whites and 28.70% among blacks, with no racial disparity, and no effect of age at diagnosis.

FEMALE LUNG CANCER A total of 14,700 women were diagnosed with lung cancer and reported to the Kentucky Cancer Registry during 1995-2005. 2,356 of these women (2,222 White, 134 African-American) were known to have remained disease-free for at least a week after initial treatment. Recurrence rates after ten years were 27.72% among whites and 31.34% among blacks, with no racial disparity, and no effect of age at diagnosis.