1. Evaluation of Childhood Cancer Incidence in Sandwich, MA: 1995 - Present Massachusetts Department of Public Health Center for Environmental Health Community Assessment Program February 28, 2006

2. 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

3. 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

4. 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

5. Steps in the Investigation  Cancer evaluation  Calculate cancer incidence rate among children diagnosed during time period 1995-2002  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

6. 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)

7. 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

8. 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

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

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

11. 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

12. 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

13. Cape Cod Childhood Cancer: 1995 – 2002 TownObservedExpectedSIR95% CI Barnstable1414.49753-163 Bourne36.2NC Brewster42.9NC Chatham11.3NC Dennis03.8NC Eastham01.3NC Falmouth99.39644-183 Harwich03.1NC Mashpee74.017570-361 Orleans11.2NC Provincetown00.5NC Sandwich107.513364-245 Truro10.5NC Wellfleet20.7NC Yarmouth65.910137-220 SIR and 95% CI not calculated when Observed is less than 5

14. Review of Cape Cod Childhood Cancer  From 1995-2002, 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

16. Childhood Cancer Incidence in Sandwich, MA: 1995-2002 ObservedExpectedSIR95% CI Males 34.0NC Females 73.520080-412 Total 107.513364-245

17. Childhood Cancer Incidence in Sandwich Census Tracts: 1995-2002 Census tracts TotalMalesFemales OBSEXPSIR95% CIOBSEXPSIR95% CIOBSEXPSIR95% CI 0133 10.9NC 00.4NC 10.4NC 0134 21.3NC 10.7NC 10.6NC 0135 52.619262-44911.4NC 41.2NC 0136 22.7NC 11.4NC 11.2NC Town 107.513364-24534.0NC 73.520080-412

18. Cancer Types Diagnosed 1995-2002 Leukemia3 children CNS Tumor3 children Soft Tissue Sarcoma2 children Lymphoma (Hodgkin’s Disease) 1 child Bone1 child

19. Distribution of Childhood Cancer Diagnoses: 1995 - 2002

20. Cancer Types Diagnosed 2003-2005 Leukemia3 children CNS Tumor2 children Bone2 children

21. Distribution of Childhood Cancer Diagnoses: 2003 - 2005

22. 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

23. What Do We Know About Childhood Cancer? Hodgkin’s Disease (HD)  Ages 15-19  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

24. 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 15-19  Pre-existing medical conditions (e.g., Li-Fraumeni syndrome, Beckwith-Wiedemann syndrome and Neurofibromatosis)  Treatment with ionizing radiation  Exposure to pesticides

25. Summary of Results 1995-2002  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

26. Summary of Results 1995-2002  For 3 of 4 Sandwich CTs observed was close to the expected  From 1996-1999, 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

27. Summary of Results 2003 – 2005  From 2003-2005, 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

28. Geographic Distribution 1995 - 2005  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

29. 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 0133100%  CT 0136 90%  CT 0134 55%  CT 0135 36% *Source: 1990 US Census Data

30. 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

31. 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

32. 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

33. Contact Information The full report is available at: http://www.mass.gov/dph/cehhttp://www.mass.gov/dph/ceh. CAP staff can be reached at: Phone: (617) 624-5757 Fax: (617) 624-5777