A first look at cancer incidence rates and trends in Bermuda over the 10-year period 2007-2016 Sarah Crooks IARC Caribbean Cancer Registry Hub Caribbean Public Health Agency (CARPHA) Trinidad and Tobago NAACCR /IACR Combined Annual Conference June 11 – 13, 2019 Vancouver, BC, Canada

The IARC Caribbean Cancer Registry Hub One of six regional IARC Hubs worldwide Became operational in 2015 Based at the Caribbean Public Health Agency (CARPHA), in Port of Spain, Trinidad & Tobago Operations managed by 3 CARPHA staff members with technical and financial support provided by multiple partners (NCI, NAACCR, IARC, CDC, PAHO) MISSION: To improve the availability, use and dissemination of high-quality cancer data to inform cancer control in the Caribbean region

Bermuda One of 6 British Overseas Territory in the Caribbean Associate Member of the Caribbean Community (CARICOM) Located in the North Atlantic Ocean roughly 1000km east of North Carolina Consists of approximately 138 islands, 7 of which are populated and connected by bridges 20.5 square mile land area Population: 61,695 (2016) A high-income country with over 98% population-wide health insurance coverage and one of the highest per capita health expenditure rates worldwide Culturally, collaboratively and historically Bermuda is inextricably linked to the Caribbean, however, geographically, Bermuda is typically not referred to as a “Caribbean island” as we are located in the Atlantic Ocean as opposed to the Caribbean Sea. Highest GDP per capita in the Caribbean

Bermuda National Tumour Registry A population-based cancer registry Located in the King Edward VII Memorial Hospital Established in 1979 Data accepted into CI5 VI Submission of data to CI5 – Submitted data for CI5 X but it was not accepted. They are keen to submit data but need better feedback and guidance from IARC. King Edward VII Memorial Hospital is one of three hospitals that comprise the Bermuda Hospitals Board (BHB). Katura - In 2004 she made history by becoming the first black woman, in the world, to compete in the Olympics as a diver. Katura Horton-Perinchief Manager, Bermuda National Tumour Registry September 2008 - present

Methods A “Data Use Agreement” between the Bermuda National Tumour Registry and the IARC Caribbean Cancer Registry Hub was completed and signed Time Period: 2007-2016 Data Sources: Incidence data - Bermuda National Tumour Registry Population estimates - Department of Statistics Software: CanReg 5.00.43, Excel, SEER*Stat Analyses: Cancer incidence rates and trends generated for the 10 year period ASR for the combined period 2014-2016 were compared to worldwide GLOBOCAN 2018 estimates Data use agreement included details on the variables and time frame of data to be shared, as well as the format required.

Katura became Manager of the Registry in late 2008 Katura became Manager of the Registry in late 2008. Efforts were made to retroactively register cases before then but the low case count in 2007 is not that surprising. Average annual incidence = 265.9

High prostate cancer rates; increasing trend from 2011-2014 High prostate cancer rates; increasing trend from 2011-2014. Trend likely due to: - Amped up effort to encourage men to get screened -Increase in health education -Increased reporting by urologist who were initially hesitant to report cases Cervix uteri is relatively low for women (not on chart). This is likely due to cervical cases being caught very early; most in the pre-cancerous stage. Yearly screening is covered under the Standard Health Benefit and ongoing health education efforts around HPV and cervical cancer. Over the combined 10-year period, excluding non-melanoma skin cancer: Among men: prostate cancer ASR: 80.9 lung ASR: 28.6 colon ASR: 22.6 bladder ASR: 16.3 Among women: breast cancer ASR: 87.9 colon ASR: 21.3 lung ASR: 11.8 corpus uteri ASR: 11.3

Age-standardized incidence rates, All cancers For all cancers combined, 2014-2016 cancer incidence in Bermuda (ASR: Males 356.4, Females 256.6) is higher than that estimated worldwide (ASR: Males 218.6, Females 182.6). ASR for 2014-2016 for Bermuda were 63% higher for men and 41% higher for women compared to GLOBOCAN 2018 Worldwide ASR for all cancers.

Comparing ASR, All Cancers USA, Bahamas and Worldwide rates taken from GLOBOCAN 2018. Bahamas is a similarly high-income, northern Caribbean country with a comparable demographic profile to Bermuda. Bermuda’s rates are higher than the worldwide rates and the rates estimated for the Bahamas. However, the rates are lower than those estimates for the USA for both sexes.

Among women in Bermuda: the ASR for breast cancer, colorectal cancer, melanoma of the skin and Non-Hodgkins lymphoma are each roughly double the worldwide estimates Rates for lung cancer, liver cancer, leukemia and cervical cancer were lower than worldwide estimates It should be noted that the large majority of cases are diagnosed on island. Some cases, are however, diagnosed and treated off island (US, UK, Canada) and are likely not registered, for eg. any diagnosis that is made via PET CT, is made off island and childhood cancers are mainly diagnosed and treated off island. These cases may or may not be registered. Interesting patterns that need further research.

Among men: Prostate cancer rates were roughly three times higher in Bermuda than worldwide Colorectal cancer rates were twice as high in Bermuda than worldwide Rates for liver cancer and leukemia were lower in Bermuda than worldwide estimates Again, interesting patterns are seen among men. This may be indicative that the "world" is not a good comparison group for Bermuda or perhaps, there may be some issues in Bermuda, which are influencing these rates which are out of sync with the global burden. Either way, further investigation is needed.

Likely contributing factors: Determining the reasons underlying the disproportionately high incidence rates for some cancers in Bermuda requires further investigation and clinical/epidemiological research. Likely contributing factors: Relatively high national health care financing which may influence health seeking behavior and result in increased screening and detection of cancers High prevalence of chronic disease risk factors in the population Health screening in Bermuda: There has been no policy change over the time period. Colonoscopies and mammograms have always been covered under the Standard Health Benefit Interesting fact: the Bermuda grapevine is fierce. Bermuda is small so there is a lot of pressure to tow the line within families. Many families go together for their screenings. Health education/health promotion efforts are highly effective, e.g. when women are told to get mammograms, they get them.

Next Steps The IARC Caribbean Cancer Registry Hub will continue to work with the Bermuda National Tumour Registry to explore some of the key differences and interesting trends observed for Bermuda Broaden analyses: incorporate more recent data, include smoothing and/or Joinpoint analyses Include stakeholders from the Ministry of Health: National Epidemiologist, Chief Medical Officer of Health Generate internal reports and a manuscript for publication Work with IARC to provide the requested technical support to assist the Bermuda National Tumour Registry in submitting their data to the next CI5

Authors Sarah Crooks Programme Coordinator, IARC Caribbean Cancer Registry Hub CARPHA, Trinidad & Tobago Glennis Andall-Brereton Principal Investigator, IARC Caribbean Cancer Registry Hub CARPHA, Trinidad & Tobago Katura Horton-Perinchief Manager Bermuda National Tumour Registry Brenda Edwards Senior Advisor, Office of the Director, Division of Cancer Control and Population Sciences, NCI Damali Martin Global Health Coordinator, Epidemiology & Genomics Research Program, Division of Cancer Control and Population Sciences, NCI Gerri Nott Tumour Registrar Bermuda National Tumour Registry Rachel Hanisch Division of Cancer Control and Population Sciences NCI Les Mery Global Programme Manager, Cancer Surveillance Unit, IARC

Thank you Any questions?