1. NAACCR Annual Meeting Detroit, 2007 Incidence of Esophageal and Gastric Cancers Subsite and Histology Differences between Hispanics and Non-Hispanics Wu XC, Chen VW, Andrews PA, Ruiz B, Correa, PL Louisiana Tumor Registry Incidence of Esophageal and Gastric Cancers Subsite and Histology Differences between Hispanics and Non-Hispanics Wu XC, Chen VW, Andrews PA, Ruiz B, Correa, PL Louisiana Tumor Registry

2. Outline Background information Background information Objective Objective Methods Methods Results Results Discussion Discussion

3. Background information Hispanics/Latinos constitute the largest and the fastest growing minority group in the United States. Hispanics/Latinos constitute the largest and the fastest growing minority group in the United States. From 1990 to 2000, the U.S. Hispanic population increased by 58%. According to the 2000 U.S. Census, Hispanics account for 13% of U.S. population. From 1990 to 2000, the U.S. Hispanic population increased by 58%. According to the 2000 U.S. Census, Hispanics account for 13% of U.S. population.

4. Background information Gastric cancer is one of the few cancers for which Hispanic population has a higher incidence rate than non-Hispanics. Gastric cancer is one of the few cancers for which Hispanic population has a higher incidence rate than non-Hispanics. Esophageal cancer occurs less frequently among Hispanics than non-Hispanics even though it shares some risk factors as gastric cancer. Esophageal cancer occurs less frequently among Hispanics than non-Hispanics even though it shares some risk factors as gastric cancer.

5. Background information Previous studies have suggested that the magnitude of risk for the same risk factors differs by histology and subsite for esophageal and gastric cancers (El-Serag H, 2002; Zhang Z, 1996). Previous studies have suggested that the magnitude of risk for the same risk factors differs by histology and subsite for esophageal and gastric cancers (El-Serag H, 2002; Zhang Z, 1996). The attributable risk of the same factors may vary from population to population (Brown L, 2000; Engel L, 2003). The attributable risk of the same factors may vary from population to population (Brown L, 2000; Engel L, 2003).

6. Background information Information on subsite- and histology-specific incidence of these diseases is limited for Hispanics in the literature. Information on subsite- and histology-specific incidence of these diseases is limited for Hispanics in the literature. One recent study examined multi-ethnic variations of esophageal and gastric cancers using data from SEER Program. But non- cardia gastric adenocarcinoma was not included (Kubo A, 2004). One recent study examined multi-ethnic variations of esophageal and gastric cancers using data from SEER Program. But non- cardia gastric adenocarcinoma was not included (Kubo A, 2004).

7. Objective Examine esophageal and gastric cancer incidence rates by subsite and histology among Hispanics and compare them with those of non-Hispanics. Examine esophageal and gastric cancer incidence rates by subsite and histology among Hispanics and compare them with those of non-Hispanics.

8. Methods – data source We used 1998-2002 cancer incidence data from 37 population-based cancer registries, covering 68% of US population including 66% of Hispanic population. We used 1998-2002 cancer incidence data from 37 population-based cancer registries, covering 68% of US population including 66% of Hispanic population. Ethnicity was coded based on information from medical records and NAACCR’s Hispanic identification algorithm (NHIA). Ethnicity was coded based on information from medical records and NAACCR’s Hispanic identification algorithm (NHIA).

9. Methods – inclusion criteria Invasive cancer Invasive cancer Topographic codes (ICD-O-3) Topographic codes (ICD-O-3) - Esophageal cancer: C15.0-C15.9 - Gastric cancer: C16.0-C16.9 No lymphoma No lymphoma Microscopically confirmed only (6%) Microscopically confirmed only (6%)

10. Methods – esophageal anatomic subsites Proximal & middle segments: Proximal & middle segments: - cervical esophagus (C15.0) - upper third of esophagus (C15.3) - middle third of esophagus (C15.4) Distant segment Distant segment - abdominal esophagus (C15.2) - lower third of esophagus (C15.5) Unspecified Unspecified - thoracic esophagus (C15.1) - thoracic esophagus (C15.1) - overlapping (C15.8) - overlapping (C15.8) - esophagus, NOS (C15.9) - esophagus, NOS (C15.9)

11. Methods - gastric anatomic subsites Cardia (C16.0) Cardia (C16.0) Noncardia (C16.1-C16.6) Noncardia (C16.1-C16.6) - fundus and corpus (C16.1-C16.2) - antrum and pylorus (C16.3-C16.4) - antrum and pylorus (C16.3-C16.4) - curvatures (C16.5-C16.6) Unspecified (C16.8-C16.9) Unspecified (C16.8-C16.9) - overlapping (C16.8) - overlapping (C16.8) - stomach, NOS (C16.9) - stomach, NOS (C16.9)

12. Methods - histology types Squamous cell carcinoma (SCC) Squamous cell carcinoma (SCC) ICD-O-3 morphology codes: M8050-M8084 Adenocarcinoma Adenocarcinoma ICD-O-3 morphology codes: M8140-M8576 Others Others

13. Methods – statistical analysis The following statistics were generated by subsite and histology for Hispanics and non- Hispanic whites (NHW). The following statistics were generated by subsite and histology for Hispanics and non- Hispanic whites (NHW). - relative frequencies - age-adjusted (2000 U.S) incidence rates - rate ratios and 95% CI

14. Outline Background information Background information Objective Objective Methods Methods Results Results Discussion Discussion

15. Histology Types of Esophageal Cancer by Race/Ethnicity 1998-2002, Men Histology type Hispanics(%)NHW(%) SCC50.324.2 Adenocarcinoma43.070.1 Others6.75.6 Total100.0100.0

16. Histology Types of Esophageal Cancer by Race/Ethnicity 1998-2002, Women Histology type Hispanics(%)NHW(%) SCC56.850.4 Adenocarcinoma35.142.2 Others8.17.4 Total100.0100.0

17. Rates* and Rate Ratios of Esophageal Cancer 1998-2002, Men Histology typeHispanicsNHWRR (95% CI) SCC2.941.99 1.48 (1.35-2.61) Adenocarcinoma2.425.71 0.42 (0.38-0.47) Others0.400.47 0.85 (0.66-1.10) * Age-adjusted (2000 U.S.) rate per 100,000

18. Rates* and Rate Ratios of Esophageal Cancer 1998-2002, Women Histology typeHispanicsNHWRR (95% CI) SCC0.860.93 0.93 (0.81-1.07) Adenocarcinoma0.520.78 0.67 (0.56-0.80) Others0.120.13 0.94 (0.63-1.36) * Age-adjusted (2000 U.S.) rate per 100,000

19. Rates of Esophageal Cancer by Histology and Anatomic Subsite, 1998-2002, Men The rates of SCC were significantly higher in Hispanics than NHW for proximal & middle segments and unspecified subsite group. The rates of SCC were significantly higher in Hispanics than NHW for proximal & middle segments and unspecified subsite group. The rates of adenocarcinoma were significantly lower in Hispanics than NHW for all anatomic subsites. The rates of adenocarcinoma were significantly lower in Hispanics than NHW for all anatomic subsites.

20. Rates of Esophageal Cancer by Histology and Anatomic Subsite, 1998-2002, Women For SCC, there were no significant differences between Hispanics and NHW for all anatomic subsites. For SCC, there were no significant differences between Hispanics and NHW for all anatomic subsites. The rates of adenocarcinoma were significantly lower in Hispanics than NHW for proximal & middle segments and distal segment. The rates of adenocarcinoma were significantly lower in Hispanics than NHW for proximal & middle segments and distal segment.

21. Histology Types of Gastric Cancer by Race/Ethnicity 998-2002 Sex/histologyHispanics(%)NHW(%) Men Adenocarcinoma Adenocarcinoma Others Others 93.9 6.1 6.1 92.0 8.0 8.0 Women Adenocarcinoma Adenocarcinoma Others Others 92.9 7.1 7.1 90.4 9.6 9.6

22. Anatomic Subsites of Gastric Adenocarcinoma by Race/Ethnicity, 1998-2002, Men Anatomic subsite Hispanics(%)NHW(%) Cardia Cardia14.840.7 Noncardia Noncardia49.331.4 Unspecified subsites Unspecified subsites29.819.8

23. Anatomic Subsites of Gastric Adenocarcinoma by Race/Ethnicity, 1998-2002. Women Anatomic subsite Hispanics(%)NHW(%) Cardia Cardia9.518.0 Noncardia Noncardia52.845.0 Unspecified subsites Unspecified subsites30.627.5

24. Rates* and Rate Ratios of Gastric Adenocarcinoma 1998-2002, Men Anatomic subsiteHispanicsNHWRR (95% CI) Cardia2.423.62 0.67 (0.61- 0.73) Noncardia8.322.95 2.82 (2.67-2.98) Unspecified subsites 5.011.84 2.72 (2.53-2.92) * Age-adjusted (2000 U.S.) rate per 100,000

25. Rates* and Rate Ratios of Gastric Adenocarcinoma 1998-2002, Women Anatomic subsiteHispanicsNHWRR (95% CI) Cardia0.860.72 1.20 (1.05-1.37) Noncardia4.901.72 2.86 (2.69-3.03) Unspecified subsites 2.691.07 2.52 (2.33-2.72) * Age-adjusted (2000 U.S.) rate per 100,000

26. Rates of Noncardia Gastric Adenocarcinoma by Anatomic Subsite Group, 1998-2002 The rates were significantly higher in Hispanics than NHW for all individual subsite groups of noncardia gastric adenocarcinoma for both men and women. The rates were significantly higher in Hispanics than NHW for all individual subsite groups of noncardia gastric adenocarcinoma for both men and women. - fundus and corpus (C16.1-C16.2) - antrum and pylorus (C16.3-C16.4) - antrum and pylorus (C16.3-C16.4) - curvatures (C16.5-C16.6)

27. Discussion Although overall rates of esophageal cancer are lower in Hispanics than NHW, the rates of esophageal SCC are statistically significantly higher in Hispanics than NHW for men. Although overall rates of esophageal cancer are lower in Hispanics than NHW, the rates of esophageal SCC are statistically significantly higher in Hispanics than NHW for men. The rates of esophageal adenocarcinoma are significantly lower in Hispanics than NHW, for both men and women. The rates of esophageal adenocarcinoma are significantly lower in Hispanics than NHW, for both men and women.

28. Discussion Overall rates of gastric cancer are singificantly higher in Hispanics than NHW, for both men and women. Overall rates of gastric cancer are singificantly higher in Hispanics than NHW, for both men and women. The rates of gastric cardia adenocarcinoma vary by sex: lower in Hispanics than NHW for men but higher in Hispanics for women. The rates of gastric cardia adenocarcinoma vary by sex: lower in Hispanics than NHW for men but higher in Hispanics for women. The rates of noncardia gastric adenocarcinoma are significantly higher in Hispanics than NHW for both men and women. The rates of noncardia gastric adenocarcinoma are significantly higher in Hispanics than NHW for both men and women.

29. Discussion The higher rate of esophageal SCC in Hispanics The higher rate of esophageal SCC in Hispanics than NHW for men cannot be explained by prevalence of the known risk factors such as tobacco smoking,alcohol consumption, and diet. than NHW for men cannot be explained by prevalence of the known risk factors such as tobacco smoking,alcohol consumption, and diet. The longitudinal data from NHIS indicate that Hispanics have the lowest prevalence of current smoking of all racial/ethnic groups over time and the percentages of persons with > 5 drinks in one day at least once in the past year are also significantly lower among Hispanics (Thompson F, 2005). The longitudinal data from NHIS indicate that Hispanics have the lowest prevalence of current smoking of all racial/ethnic groups over time and the percentages of persons with > 5 drinks in one day at least once in the past year are also significantly lower among Hispanics (Thompson F, 2005).

30. Discussion The data from the same survey also indicate that Hispanics have higher intakes of fruits and vegetables and fiber than do NHW (Thompson F, 2005). The data from the same survey also indicate that Hispanics have higher intakes of fruits and vegetables and fiber than do NHW (Thompson F, 2005). Kaiser Permanent Medical Care Program (KPMCP) study found that Hispanics were less likely than NHW to eat vegetables and fruits (Otero-Sabogal R, 1995). Kaiser Permanent Medical Care Program (KPMCP) study found that Hispanics were less likely than NHW to eat vegetables and fruits (Otero-Sabogal R, 1995).

31. Discussion Chronic gastroesophageal reflux disease (GERD) and obesity have been found to have strong associations with occurrence of esophageal and gastric cardia adenocarcinoma (Lagergren J, 1999; Brown L, 1995). Chronic gastroesophageal reflux disease (GERD) and obesity have been found to have strong associations with occurrence of esophageal and gastric cardia adenocarcinoma (Lagergren J, 1999; Brown L, 1995). One study found that prevalence of Barrett’s esophagus was similar in Hispanics and whites (Bersentes K, 1998). One study found that prevalence of Barrett’s esophagus was similar in Hispanics and whites (Bersentes K, 1998).

32. Discussion The prevalence of obesity is about the same in Hispanics and whites for men but higher in Hispanics than whites for women (Denney J, 2004). The prevalence of obesity is about the same in Hispanics and whites for men but higher in Hispanics than whites for women (Denney J, 2004). Smoking is a major risk factor for esophageal and gastric cardia adenocarcinoma, accounting for approximately 40% of cases (Gammon MD, 1997). Smoking is a major risk factor for esophageal and gastric cardia adenocarcinoma, accounting for approximately 40% of cases (Gammon MD, 1997).

33. Discussion It is not clear the role of dietary factors plays in the substantially higher rates of noncardia gastric cancer in Hispanics than NHW. It is not clear the role of dietary factors plays in the substantially higher rates of noncardia gastric cancer in Hispanics than NHW. Many traditional dietary commodities have not appropriately evaluated. It is not clear if they contain some high levels of nitrate, which is a risk factor for gastric cancer. Many traditional dietary commodities have not appropriately evaluated. It is not clear if they contain some high levels of nitrate, which is a risk factor for gastric cancer.

34. Discussion Helicobacter pylori infection has emerged as an important risk factor for gastric cancer (Correa P, 1991; Hansson L, 1993).. It appears that Helicobacter pylori infection is most likely to contribute to the high incidence rates of noncardia gastric adenocarcinoma in Hispanics than NHW.

35. Discussion Prevalence of H pylori infection is higher in developing countries than developed countries (EUROGAST study group, 1993). Prevalence of H pylori infection is higher in developing countries than developed countries (EUROGAST study group, 1993). Poor hygiene and crowded living condition facilitate the transmission of the infection among family members (Brown L, 2000). Poor hygiene and crowded living condition facilitate the transmission of the infection among family members (Brown L, 2000). The infection is predominantly acquired in childhood and tends to stay active unless it is treated with antibiotics (Banatvala N, 1993; Correa P, 2003). The infection is predominantly acquired in childhood and tends to stay active unless it is treated with antibiotics (Banatvala N, 1993; Correa P, 2003). In the U.S. 40% of Hispanics are foreign born and a high percentage of them lives in poverty. In the U.S. 40% of Hispanics are foreign born and a high percentage of them lives in poverty.

36. Discussion The data from the National Health and Nutrition Examination Survey (NHANES) III indicate the sero-prevalence of H pylori is significantly higher in Mexican Americans than NHW (63% vs. 24%) (McQuillan G, 2005). The data from the National Health and Nutrition Examination Survey (NHANES) III indicate the sero-prevalence of H pylori is significantly higher in Mexican Americans than NHW (63% vs. 24%) (McQuillan G, 2005).

37. Concluding remarks Observed cancer incidence patterns cannot be explained clearly by what we know about prevalence of a few known risk factors. Observed cancer incidence patterns cannot be explained clearly by what we know about prevalence of a few known risk factors. Information on prevalence of risk factors is needed, especially for Hispanic population. Information on prevalence of risk factors is needed, especially for Hispanic population. Research on effect of traditional diet, genetic polymorphism, and other risk factors is warranted. Research on effect of traditional diet, genetic polymorphism, and other risk factors is warranted.

38. ACKNOWLEDGEMENTS This study was supported by NAACCR, in cooperation with Louisiana Tumor Registry/School of Public Health, LSUHSC with funds from the National Cancer Institute, National Institutes of Health, Department of Health and Human Services, under Contract No. HSN261200444001C and ADB No. N02-PC 4401.

39. Publication The manuscript from this study has been published in Cancer Causes and Control, April 4, 2007. For a copy of this manuscript, please email me at xwu@lsuhsc.edu For a copy of this manuscript, please email me at xwu@lsuhsc.edu