1. The Genetic Component of a Common Disease The Paradigm of Cancer Genetics John Quillin, PhD, MPH, MS Virginia Commonwealth University Summer, 2006

2. The Plan  Introduce/discuss case study  Epidemiology of cancer  Tailored prevention  Resources

3. What’s Going On Here?  Your neighbor and two of her daughters have had breast cancer. A gentleman across the street died from lung cancer last year, and a young girl next door to him was just diagnosed with leukemia.  Is there a “true” cluster of cancer on your street? If not chance, what’s the cause?  How can you as a public health official investigate, understand, and intervene?

4. Cancer Epidemiology A Brief Overview  Lifetime chance ~42% (SEER, 2002)  Common risk factors Age Diet Smoking (30% of cancer) Genetics/Inherited Factors

5. * For those free of cancer at beginning of age interval. Based on cancer cases diagnosed during 2000 to 2002. Source: DevCan: Probability of Developing or Dying of Cancer Software, Version 6.0 Statistical Research and Applications Branch, NCI, 2005. http://srab.cancer.gov/devcan Lifetime Probability of Developing Cancer, by Site, Men, 2000-2002* † All Sites exclude basal and squamous cell skin cancers and in situ cancers except urinary bladder. SiteRisk All sites † 1 in 2 Prostate 1 in 6 Lung and bronchus1 in 13 Colon and rectum1 in 17 Urinary bladder ‡ 1 in 28 Non-Hodgkin lymphoma1 in 46 Melanoma1 in 52 Kidney1 in 64 Leukemia1 in 67 Oral Cavity1 in 73 Stomach1 in 82 ‡ Includes invasive and in situ cancer cases

6. Lifetime Probability of Developing Cancer, by Site, Women, US, 2000-2002* SiteRisk All sites † 1 in 3 Breast 1 in 8 Lung & bronchus 1 in 17 Colon & rectum 1 in 18 Uterine corpus 1 in 38 Non-Hodgkin lymphoma 1 in 55 Ovary 1 in 68 Melanoma 1 in 77 Pancreas 1 in 79 Urinary bladder ‡ 1 in 88 Uterine cervix 1 in 135 Source: DevCan: Probability of Developing or Dying of Cancer Software, Version 6.0 Statistical Research and Applications Branch, NCI, 2005. http://srab.cancer.gov/devcan * For those free of cancer at beginning of age interval. Based on cancer cases diagnosed during 2000 to 2002. † All Sites exclude basal and squamous cell skin cancers and in situ cancers except urinary bladder. ‡ Includes invasive and in situ cancer cases

7. Cancer Epidemiology A Brief Overview  Lifetime chance ~42% (SEER, 2002)  Common risk factors Age Diet Smoking (30% of cancer) Genetics/Inherited Factors

8. Inherited Factors Environmental Exposures

9. All Cancers: Alcohol (4%), Smoking (29%), Low fruit/vegetable (3%), Indoor smoke from household use of solid fuels (0%), Urban air pollution (1%), Overweight/obesity (3%), Physical inactivity (2%), Contaminated injections in health-care settings (0.5%), Unsafe sex (1%) Lancet 2005;366:1784-93.

10. Lichtenstein et al. NEJM 2000;343(2)73-85

11. Public Health Interventions  Primary prevention ACS 5-a-day Exercise Prevent smoking initiation Chemoprevention Risk-Reducing Surgery

12. Public Health Interventions  Secondary Prevention (Screening) Radiology (Mammography, Colonoscopy, other) Clinical and self-examinations Molecular markers

13. Public Health Interventions  Tertiary Prevention (Screening) Prevent recurrence and/or new primary  Chemotherapy, radiation, surgery, screening Address comorbidity and iatrogenic complications

14. Challenge of One-Size-Fits-All Approach  Expensive  Potentially harmful (unnecessary surgery, radiation exposure, etc.)  Tailored education may be more effective  We can do better

15. How Best To Triage?  Age Initiating screening appropriately  Diet Targeted interventions (school lunches, food labeling)  Genetics Family history Genetic testing

16. Is It Genetic?  Cancer clusters Higher-than-expected rate of cancer in geographically-defined area  Challenges It’s a big country Not coincidence if it happens to you Media influential Are we exploring all the options?

17. Genetic Cancer Clusters  1 st -degree relative  RR ~2-4  About 25% cancers familial, 5-10% Mendelian Early age Multiple primary cancers Hereditary/Syndromic pattern Positive genetic test

18. Hereditary Cancer Breast Ca 55 55 YO Bil Breast Ca 65, 79 83 YO Lung Ca 66 Smoked, Asbestos d. 76 YO Ovarian Ca 79 d. 79 YO Bil Breast Ca 66, 74 d. 78 YO Heart prob d. Late 70s Breast Cancer Ovarian Cancer Family tested negative for genetic changes

19. Long Island Breast Cancer Study  Breast Cancer Res Treat. 2002 Jun;74(3):235-54.  Overall, modest increase in breast cancer  Many negative environmental findings  Family history common risk factor among cases

20. Family History as a Public Health Tool  Note Am J Prev Med 2(24); Feb 2003  Is family history obtained?  Is it accurate/known?  Cancer registries VDH (http://www.vdh.state.va.us/epi/cancer/index.asp)http://www.vdh.state.va.us/epi/cancer/index.asp MACGN (www.macgn.org)www.macgn.org  Other initiatives http://www.hhs.gov/familyhistory/ http://www.cdc.gov/genomics/

21. Challenges  Family communication  Access to expert health services  Concerns about confidentiality and/or discrimination