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 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 Environmental Occupational Lifestyle Family History Genetics Interactions

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 Environmental Occupational (18%) Lifestyle (68%) Family History Genetics (13%) Interactions

Colorectal cancer as a % of all cancers incidence cases and deaths.

Comparing colorectal cancer incidence and mortality in Kentucky to the U.S.

Colorectal Cancer Incidence Rates in the U.S. Compared to 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 ( ) 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 ( ) 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 ( ) 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.

Demographic Characteristics Contribute to Risk Factors Contribute to Incidence and Late Stage DX Contribute to Cancer Mortality Combining Data from Multiple Sources Logic Model

Common sources of data that can be used for defining the cancer burden 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 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 BurdenLowest Burden

Colorectal Cancer

Colorectal Cancer Rank for States StateCollege Ed+Colonoscopy IncidenceMortality Overall Index %Rank% RateRankRate Rank 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

Hawaii South Carolina Maine Michigan New Mexico Idaho 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 Colorectal Cancer Rank for States StateCollege Ed+Colonoscopy IncidenceMortality Overall Index %Rank% RateRankRate Rank

Colorectal Cancer by Area Development District in KY, Area Development District High School Education (%) Poverty Rate (%) Colorectal Cancer Screening Rate (%) Age-Adjusted Incidence Late Stage Incidence % Age-Adjusted Mortality NumberRateNumberRate 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 Cancer by Area Development District in KY, Area Development District High School Education, Colorectal Cancer Screening, Late Stage Incidence Overall Rank PercentRankPercentRankRateRank Kentucky River Buffalo Trace Gateway Cumberland Valley Lake Cumberland Barren River Big Sandy Lincoln Trail Pennyrile Green River Fivco Northern Kentucky Bluegrass Purchase Kipda

Unique KY Resources for Cancer Control Kentucky Cancer Registry (KCR) Kentucky Cancer Program (KCP)Kentucky Cancer Consortium (KCC) Lung Cancer by Area Development District in KY, Area Development District High School Education Current Smokers Age- Adjusted Incidence Age- Adjusted Mortality Overall Rank PercentRankPercentRankRateRankRateRank Kentucky River Big Sandy Cumberland Valley Gateway Buffalo Trace Barren River Lake Cumberland Fivco Green River Pennyrile Lincoln Trail Purchase Northern Kentucky Kipda Bluegrass

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 49 th 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% 60% 50% 40% 30% % 47.2% 43.9% 34.7% % 49 th in the U.S. 20 th 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.

P<.05 Source: Accessed May, 2013http://cancer-rates.info/ky

P<.05 Source: Accessed May, 2013http://cancer-rates.info/ky

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! Questions The End Contact Information: Thomas C.Tucker, PhD, MPH The Kentucky Cancer Registry acknowledges the Centers for Disease Control and Prevention for its support under cooperative agreement U58DP and the National Cancer Institute for its support under contract number N01PC