2. 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

3. 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.

4. Factors that contribute to the onset of cancer.

5. Factors Contributing to the Onset of Cancer Environmental Occupational Lifestyle Family History Genetics Interactions

6. 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

7. 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.

8. Factors Contributing to the Onset of Cancer Environmental Occupational (18%) Lifestyle (68%) Family History Genetics (13%) Interactions

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

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

15. Colorectal Cancer Incidence Rates in the U.S. Compared to Kentucky (2005-2009) Rates per 100,000 persons and age-adjusted to the 2000 U.S. standard population

16. Colorectal Cancer Mortality Rates in the U.S. Compared to Kentucky (2005-2009) Rates per 100,000 persons and age-adjusted to the 2000 U.S. standard population

17. Colorectal Cancer Incidence Rates in the U.S. Compared to Kentucky (2005-2009) Rates per 100,000 persons and age-adjusted to the 2000 U.S. standard population

18. Colorectal Cancer Mortality Rates in the U.S. Compared to Kentucky (2005-2009) Rates per 100,000 persons and age-adjusted to the 2000 U.S. standard population

19. States ranked by colorectal cancer incidence and mortality rates.

20. Both Genders, Colorectal Cancer Incidence Rates Ranked by State (2005 – 2009)

21. Both Genders, Colorectal Cancer Mortality Rates Ranked by State (2005 – 2009)

22. Trends in Kentucky colorectal cancer incidence and mortality rates.

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

29. 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)

30. 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.

31. 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

32. 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

33. 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

34. 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.

35. 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

36. Colorectal Cancer

38. Colorectal Cancer Rank for States 2008-09 StateCollege Ed+Colonoscopy IncidenceMortality Overall Index %Rank% RateRankRate Rank Mississippi19.5353.5253.8224.718 Louisiana20.9551.2153.6323.7312 West Virginia17.3154.1552.4622.4517 Kentucky20.3461.43057.1123.5439 Arkansas19.1254.0445.42622.0840 Oklahoma22.6953.5348.01621.61341 Alabama21.7657.11452.1821.51543 Indiana22.4857.91849.11421.81050 Nebraska27.73155.11050.71222.2659 Nevada21.8755.51145.12721.51459 Ohio24.11359.02247.61821.81164 Illinois30.33757.41752.6522.0766 Tennessee22.71057.91947.32121.01767 Pennsylvania26.42660.72953.2421.71271 Alaska27.02856.61352.3720.12472 Iowa24.51559.82751.21120.61972 Missouri25.01759.62449.11520.81874 North Dakota26.32557.21651.51019.72677 Wyoming23.61154.4641.94019.52784 South Dakota25.31859.32347.02220.22386 New Jersey34.64458.52149.41321.9987 Texas25.82056.21243.53619.23199 Montana27.93254.8845.52518.337102

39. Hawaii29.43457.21551.9916.048106 South Carolina24.01262.63241.94120.222107 Maine26.52768.54347.52020.321111 Michigan25.01667.44043.63520.320111 New Mexico25.51954.4738.94717.940113 Idaho24.31454.9940.64516.946114 Georgia27.22959.72644.63319.529117 North Carolina26.12364.33444.93018.932119 Washington DC49.24966.73944.83124.32121 Florida25.92261.63143.43718.634124 New York32.14164.83547.61919.430125 California30.13658.52044.63217.742130 Delaware27.73071.44945.02919.925133 Wisconsin25.82165.73840.74418.239142 New Hampshire32.94267.94246.32318.536143 Oregon28.63363.83342.23918.338143 Arizona26.32460.42836.04817.144144 Maryland35.74669.14543.23821.216145 Massachusetts38.34868.94446.12418.833149 Connecticut35.24569.14647.91717.045153 Rhode Island30.33869.34744.63418.535154 Virginia33.84367.64141.94219.528154 Minnesota31.44069.64845.12817.841157 Colorado35.94759.62540.04617.543161 Washington31.03965.03641.84316.647165 Utah29.43565.13734.24914.549170 Colorectal Cancer Rank for States 2008-09 StateCollege Ed+Colonoscopy IncidenceMortality Overall Index %Rank% RateRankRate Rank

40. Colorectal Cancer by Area Development District in KY, 2005-2009 Area Development District High School Education (%) 2006-2010 Poverty Rate (%) 2006- 2010 Colorectal Cancer Screening Rate (%) 2006-2010 Age-Adjusted Incidence Late Stage Incidence % Age-Adjusted Mortality NumberRateNumberRate U.S. 87.615.1 Kentucky81.017.462.21337358.851.4441019.6 Barren River78.619.156.086359.057.128619.6 Big Sandy69.025.255.759868.852.317821.2 Bluegrass84.716.967.3202754.549.968318.7 Buffalo Trace73.322.454.521765.954.47523.1 Cumberland Valley 67.828.754.475657.751.728622.2 Fivco78.219.560.052562.849.515719.3 Gateway73.725.255.828166.855.09823.5 Green River83.015.562.764653.153.820716.9 Kentucky River 65.629.250.844068.456.214022.5 Kipda86.414.367.3292660.049.295819.8 Lake Cumberland 70.924.355.570657.152.822117.9 Lincoln Trail82.714.859.683963.353.127021.0 Northern Kentucky 86.411.464.6116958.452.341321.2 Pennyrile80.118.557.671057.351.721917.8 Purchase83.016.366.867053.744.721916.9

44. Colorectal Cancer by Area Development District in KY, 2005-2009 Area Development District High School Education, 2006- 2010 Colorectal Cancer Screening, 2006-2010 Late Stage Incidence Overall Rank PercentRankPercentRankRateRank Kentucky River65.6150.8156.224 Buffalo Trace73.3554.5354.4412 Gateway73.7655.8655.0315 Cumberland Valley 67.8254.4251.71115 Lake Cumberland70.9455.5452.8715 Barren River78.6856.0757.1116 Big Sandy69.0355.7552.3816 Lincoln Trail82.71059.6953.1625 Pennyrile80.1957.6851.71027 Green River83.01162.71153.8527 Fivco78.2760.01049.51330 Northern Kentucky 86.41564.61252.3936 Bluegrass84.71367.31449.91239 Purchase83.01266.81344.71540 Kipda86.41467.31549.21443

45. 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, 2005-2009 Area Development District High School Education 2006-2010 Current Smokers 2001-2005 Age- Adjusted Incidence Age- Adjusted Mortality Overall Rank PercentRankPercentRankRateRankRateRank Kentucky River65.6135.71124.7299.815 Big Sandy69.0335.52131.7196.228 Cumberland Valley67.8235.53117.2386.0311 Gateway73.7632.06102.1679.9422 Buffalo Trace73.3533.0496.91178.3525 Barren River78.6831.87105.8478.0625 Lake Cumberland70.9431.110101.2777.7728 Fivco78.2732.5599.9871.01030 Green River83.01130.311105.0576.1835 Pennyrile80.1931.3897.21070.11138 Lincoln Trail82.71031.1996.31266.41546 Purchase83.01228.51497.7969.41247 Northern Kentucky86.41529.01296.21371.4949 Kipda86.41428.61394.91466.61455 Bluegrass84.71328.21592.61568.01356

46. An Example In 2001, Kentucky had the highest colorectal cancer incidence rate in the U.S. compared to all of the other states

47. 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).

48. 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?

49. Colorectal Cancer Screening in Kentucky 70% 60% 50% 40% 30% 200220042006 58.6% 47.2% 43.9% 34.7% 200819992010 63.7% 49 th in the U.S. 20 th in the U.S.

50. 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.

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

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

53. 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.

54. 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.

57. Thank You! Questions The End Contact Information: Thomas C.Tucker, PhD, MPH tct@kcr.uky.edu The Kentucky Cancer Registry acknowledges the Centers for Disease Control and Prevention for its support under cooperative agreement U58DP000810 and the National Cancer Institute for its support under contract number N01PC-2010-00031.