1. GEOGRAPHIC CLUSTERS OF HEAD & NECK CANCER IN FLORIDA Recinda Sherman, MPH, CTR Florida Cancer Data Systems NAACCR Detroit, June 7, 2007

2. 2 Cancer Detection & Surveillance A priori versus posteriori  Routine surveillance versus reactive cluster investigations Increases likelihood of identifying a true cluster  Identify areas in need of targeted prevention activities Proactive versus Reactive  Cluster concern response more thorough, timely, consistent and scientific  Rapid intervention

3. 3 University of Miami Team Science Project Team Science Grant  Multi-disciplinary, multi-investigator and multi-project program  Build research infrastructure at Florida institutions GIS Related Project Aims:  Identify areas of Florida in need of primary prevention by mapping county-level smoking prevalence data Enhanced BRFSS survey data  Identify areas of Florida in need of secondary and tertiary prevention by identifying tobacco-associated cancer clusters  Identify areas in Florida in need of secondary and tertiary prevention by identifying cancer clusters of late-stage tobacco-associated cancers

4. 4 Spatial Analysis Project Objectives Develop new cluster detection surveillance model for Florida  Investigate technology SaTScan, ClusterSEER  Quantify methodological limitations  Systematic framework for identifying communities at risk

5. 5 Methods Head & Neck cancers  Oral cavity plus larynx Age 30+  Block-group level rates  1998-2002 Most closely align with US Census 2000 SatScan  Free Developed jointly by Martin Kulldorff, the NCI, and Farzad Mostashari of NYC Department of Health and Mental Hygiene  Poisson Model Identify areas at increased risk Adjusted by age, sex, etc (limited by denominator data)  Bernoulli Model Identify areas at increased risk of late-stage diagnosis

6. 6 Spatial Scan Statistic To detect & evaluate clusters in space and/or time Circular window across a geographic area Window is centered on each of several possible locations in the region and O/E calculated at each location Window varies in size and location  Infinite number of distinct geographic circles  Each circle is a possible cluster Further reading: Bernoulli and Poisson Models: Kulldorff M. A spatial scan statistic. Communications in Statistics: Theory and Methods, 26:1481-1496, 1997.

9. 9 Is it significant? ?

11. 11 Is it real? ?

12. 12 Risk Factors for Head & Neck Cancers Behavioral  Tobacco Use, Alcohol Use, HPV Infection Social  SES, Race/Ethnicity, Urban/Rural, Occupation Biological  Genetics, sex, age Environmental  ETS, contamination

13. 13 Logistic Regression Covariates Evaluated  Race  Ethnicity  Poverty  Stage  Histology  Urban/Rural status  Year of Diagnosis  HPV surrogate Age & Sex adjusted Covariates In Model  Ethnicity  Poverty  Histology  Urban/Rural Status  Year of Diagnosis  HPV surrogate

15. 15 SES Quartiles (% Living In Poverty) Relative Rate Ratio SES 1 (Highest) reference SES 21.6 ( 95% CI 1.4-1.9) SES 31.9 ( 95% CI 1.6-2.2 ) SES 4 (Lowest)3.2 ( 95% CI 2.8-3.8 )

16. Age-Adjusted Incidence Rate Trends: Florida, 1981-2002 Black Male White Male White Female Black Female

17. 17 Year of Diagnosis Relative Rate Ratio 19981.5 ( 95% CI 1.4-1.9) 19991.7 ( 95% CI 1.6-2.2) 20001.9 ( 95% CI 1.4-2.0 ) 20011.7 ( 95% CI 1.3-1.8 ) 2002reference

18. 18 Other Significant Predictors Squamous cell  OR 1.2 (95% CI 1.0-1.3) Rural residence  OR 1.5 (95% CI 1.4-1.8) Non-Hispanic ethnicity  OR 1.2 (95% CI 1.0-1.4) Cervical cancer cluster  OR 10.7 (95% 8.9-12.8)

19. 19 But can we drink the water? ?

20. 20 Point Source Evaluation ClusterSEER  Not public domain Focused test  Lawson & Waller Test Statistic  Detects focused spatial cluster in group-level data  Evaluates the pattern of disease frequency around a point-focus.  Multiple geographic areas are scored for the difference between O/E Weighted by degree of exposure to the focus.

22. 22 This facility was established in 1968 to house male inmates. The primary functions are to process newly committed male inmates into the state correctional system and to provide primary medical care to inmates within the state system. Reception and Medical Center: Florida Department of Corrections

23. 23 Data, data everywhere and not a thought to think Release of cluster data  Communicate Risk  Prioritize  Ability to follow up with intervention

24. 24 Acknowledgements: Thanks Dr. Jill MacKinnon and the staff of the FCDS  Special thanks to Jackie Button, MS, for her work investigating Florida’s jails Funding was provided by a Team Science Award from the James & Esther King Biomedical Research Programs, Florida Department of Health, and the CDC Contact: Recinda Sherman rsherman@med.miami.edu 305-243-4602