Evaluation of Childhood Cancer Incidence in Sandwich, MA: Present Massachusetts Department of Public Health Center for Environmental Health Community Assessment Program February 28, 2006

Center for Environmental Health (CEH)  Protect the public health from a variety of environmental exposures  Respond to environmental health concerns and provide communities with epidemiologic and toxicological health assessments

Community Assessment Program (CAP)  Evaluate frequency and patterns of disease in the population  Respond to concerns about suspected disease patterns or “clusters”  Investigate possible associations between environmental exposure and disease

Reason for Investigation  Concerns about increased cancer incidence among children  Requested by:  Concerned resident from Sandwich  A specific environmental concern was not reported to CAP  Reports of more recent diagnoses of cancer among children

Steps in the Investigation  Cancer evaluation  Calculate cancer incidence rate among children diagnosed during time period  Review cancer types diagnosed (1995 – present)  Evaluate geographic and temporal patterns of childhood cancer (1995 – present)  Evaluate potential environmental concerns  Public drinking water  Location of groundwater plumes from MMR

Geographic Distribution  Map locations of residence reported at time of diagnosis  Evaluate spatial patterns of childhood cancer in neighborhoods within each community  Evaluate patterns of childhood cancer in relation to environmental sources (e.g. MMR plumes)

Childhood Cancer Statistics  12,158 children in the United States were diagnosed with cancer in 2002  267 children in Massachusetts were diagnosed with cancer in 2002

Cancer in Children Versus Cancer in Adults CHILDREN  Different cancers may be more similar with respect to risk factors  Little information is known about risk factors ADULTS  Different cancers are different diseases  Much is known about risk factors for a number of cancer types

Cancer in Children Versus Cancer in Adults (cont’d) Common Childhood Cancers Leukemia CNS tumors Bone tumors Common Adult Cancers Lung Colon Breast Prostate

Statistical Methods  Standardized Incidence Ratio (SIR) SIR = Observed # of cases X 100 Expected # of cases  95% Confidence Interval

Massachusetts Cancer Registry (MCR)  Population-based surveillance system established in 1982  Massachusetts law requires reporting of all newly diagnosed primary cancers in MA residents  Confidential database

MCR (cont’d)  Statewide and city/town data are complete through 2002  Data for 2003 being prepared for release soon  Diagnoses reported to the MCR after 2002 are available for review  Contacted treatment facilities and the Rhode Island cancer registry

Cape Cod Childhood Cancer: 1995 – 2002 TownObservedExpectedSIR95% CI Barnstable Bourne36.2NC Brewster42.9NC Chatham11.3NC Dennis03.8NC Eastham01.3NC Falmouth Harwich03.1NC Mashpee Orleans11.2NC Provincetown00.5NC Sandwich Truro10.5NC Wellfleet20.7NC Yarmouth SIR and 95% CI not calculated when Observed is less than 5

Review of Cape Cod Childhood Cancer  From , the observed number of diagnoses was near or below the number of expected cases for the majority of towns on Cape Cod  Preliminary review of more recent MCR data did not suggest patterns similar to those in SE Sandwich

Childhood Cancer Incidence in Sandwich, MA: ObservedExpectedSIR95% CI Males 34.0NC Females Total

Childhood Cancer Incidence in Sandwich Census Tracts: Census tracts TotalMalesFemales OBSEXPSIR95% CIOBSEXPSIR95% CIOBSEXPSIR95% CI NC 00.4NC 10.4NC NC 10.7NC 10.6NC NC 41.2NC NC 11.4NC 11.2NC Town NC

Cancer Types Diagnosed Leukemia3 children CNS Tumor3 children Soft Tissue Sarcoma2 children Lymphoma (Hodgkin’s Disease) 1 child Bone1 child

Distribution of Childhood Cancer Diagnoses:

Cancer Types Diagnosed Leukemia3 children CNS Tumor2 children Bone2 children

Distribution of Childhood Cancer Diagnoses:

What Do We Know About Childhood Cancer? Leukemia  Most common type among children  Incidence highest in ages 2-3  Pre-existing medical conditions (e.g., Down’s syndrome)  Treatment with ionizing radiation  Exposure to drinking water contaminated with solvents and metals during pregnancy CNS Tumors  2 nd most common type  Ages 15 years and younger  Pre-existing medical conditions (e.g., Neurofibromatosis)  Family history  Treatment with ionizing radiation

What Do We Know About Childhood Cancer? Hodgkin’s Disease (HD)  Ages  Family history of HD  Infection with Epstein Barr virus  History of infectious mononucleosis Bone (Ewing’s)  Peak in incidence between ages 10 to 20  White children  Other than race, no environmental factor or other characteristic has yet been shown to be a strong risk factor

What Do We Know About Childhood Cancer? Soft Tissue Sarcoma  Rhabdomyosarcoma is the most common soft tissue sarcoma in children  Age less than 1 and children ages  Pre-existing medical conditions (e.g., Li-Fraumeni syndrome, Beckwith-Wiedemann syndrome and Neurofibromatosis)  Treatment with ionizing radiation  Exposure to pesticides

Summary of Results  Town-wide cancer incidence occurred more often than expected  Incidence among males slightly less than expected  Females were diagnosed more often than expected  The number of diagnoses per year varied between 0 and 2  Age and cancer types diagnosed were consistent with literature

Summary of Results  For 3 of 4 Sandwich CTs observed was close to the expected  From , 4 females residing in CT 0135 were diagnosed with cancer (versus 1.2 expected)  2 were diagnosed with leukemia  1 diagnosis of bone cancer  1 diagnosis of a soft tissue sarcoma

Summary of Results 2003 – 2005  From , 7 children were diagnosed with cancer  3 were diagnosed with leukemia  2 diagnoses of a CNS tumor  2 diagnoses of bone cancer  Age and cancer types diagnosed were consistent with literature

Geographic Distribution  Two areas noted in CT 0135  3 of the 6 children with leukemia lived in southeast Sandwich at the time of diagnosis  2 children diagnosed with bone cancer lived in fairly close proximity to one another in southern Sandwich

Environmental Review  Distribution did not appear to correspond to areas potentially affected by MMR plumes  Since 1993, no violations in Sandwich municipal drinking water (other than total coliform)  % of housing units on public water (estimate)*  CT %  CT %  CT %  CT % *Source: 1990 US Census Data

Recommendations for Follow-up  Conduct interviews with biological mother of children diagnosed with cancer in Sandwich from 1995-present  Pregnancy history  Family medical history  More complete residential history  Parental occupational history  Conduct interviews with mothers of children diagnosed with cancer from 1995-present in Mashpee and Barnstable  Request MCR to contact treatment facilities

Recommendations for Follow-up (cont’d)  Work with local health officials to obtain updated information on private well use  To extent possible, review additional environmental factors of concern to community

Next Steps Approval of 24A application (early March meeting) Mailing to parents with children diagnosed with cancer in Sandwich, Barnstable, and Mashpee during 1995-present Obtain written consent from parents Schedule and conduct interviews; collect medical records; obtain available environmental data Data analysis Prepare summary report of findings Schedule public release

Contact Information The full report is available at: CAP staff can be reached at: Phone: (617) Fax: (617)