1. What does the data tell us? Colorectal CANCER IN NEVADA
Paulo S Pinheiro
University Nevada Las Vegas, Roseman SM 2016

2. Aims
To analyze Nevada Central Cancer Registry (NCCR) and BRFSS data for prevalence of screening, 2014
Screening
Incidence, Mortality
Survival
TO Use SEER data to represent the US in the survival analysis
To identify issues specific to Nevada, with an emphasis on priorities for intervention

3. Nevada: How does Colorectal Cancer affect the state?
Nevada: 2.9 million
Dynamic demographics
doubled its population in the past 20 years
Highest proportion of undocumented in the Nation (8% of all population)
Diverse mix of people (race- ethnicity, long-term residents, recent arrivals)
difficult to characterize risk patterns

4. Evidence-Based Action in Nevada
Nevada Central Cancer Registry
Incidence and survival indicators
General measures: all states
Evidence-based measures: Nevada-specific
How does Nevada differ from other states?

5. Levels of Prevention Legislation on cancer prevention ↓incidence
Access to prevention care
↓ incidence
Access to quality tertiary care –↑survival, ↓mortality
Screening: ↓mortality
↓incidence
↑overall survival

6. SCREENING Lowers incidence (risk) Increases overall survival
Lowers mortality

7. Sigmoidoscopy/Colonoscopy in Nevada 2015
Demographic
Grouping N
Weighted N
Yes
Statewide
Nevada
1,688
762,113
64.1 ( )
Geography
Clark County
501
492,912
61.4 ( )
Northwestern NV
906
205,113
73.4 ( )
Balance of State
281
64,087
56.1 ( )
Race/Ethnicity
White
1,375
625,299
66.1 ( )
Black 52
63,212
67.8 ( )
Other Race
117
95,304
47.4 ( )
Hispanic
109
106,756
53.5 ( )
Education
Less than H.S.
141
101,318
45.4 ( )
H.S. or G.E.D.
581
261,736
55.6 ( )
Some Post H.S.
783
337,734
65.6 ( )
College Graduate
772
199,073
78.5 ( )
Income
< 15,000
179
83,684
50.8 ( )
$15,000 to $24,999
344
126,251
55.5 ( )
$25,000 to $34,999
239
110,486
59.5 ( )
$35,000 to $49,999
322
123,273
59.3 ( )
$50,000 to $74,999
126,919
69.6 ( )
$75,000+
552
213,227
70.7 ( )
Source: Nevada State Health Division, B Towle Aug 2016 BRFSS

8. Comparison: High-Screening States vs Nevada
Connecticut
Utah
Nevada
Combined Screening
76%
VERY HIGH
75%
64%
LOWER
AJCC STAGE DISTRIBUTION (%) I 26 21 II 24 25
III 28 31 IV 23 22
MORTALITY RATE (per 100,000)
11.8
11.0
16.9
Source: Nevada Central Cancer Registry and SEER

9. Nevada CRC Raw Numbers 1140 per year 482 per year New Cases Deaths
Source: CDC wonder

10. Colorectal Cancer Incidence 2008-2010
Men 50.6 (US 50.3)
Women 36.3 (US 38.1) 24 40 51 51 33 36 49 49
Source: CDC wonder

11. Colorectal Cancer Mortality 2011-2013
Men 19.9 (US 17.7)
Women 14.2 (US 12.4) 10 8 51 51 41 38 47 43
Source: CDC wonder

12. Incidence And Mortality Ranks For Nevada
Males:
#24 for Incidence but #10 for Mortality
Females:
#40 for Incidence but #8 for Mortality
Anything strange with this?

13. Deaths Per Year in Nevada, 2013 Leading Cancers
Men and Women
Men
Women
All Cancers
4,817
2,609
2,208
LUNG
1,335
719
616
COLORECTAL
482
264
218
BREAST
352 -
PANCREAS
325
167
158
PROSTATE
278
LEUKEMIA
196
132 64
LIVER
182
131 51
BLADDER
139
107 32
MELANOMA 68 49 19
Source: CDC wonder

14. CRC – If Nevada was just average
Of the 482 annual deaths in the state,
we could save
57 every year

15. NV MORTALITY RANK: Colorectal CANCER 2011-2013 (out of 51)
Men
Women
ALL RACES 10 8
Whites 4* 1*
Blacks 42 40
Hispanics 32 29
Asians 19 17
*Significantly higher than US average p<0.05
Source: CDC Wonder

16. SURVIVAL

17. Data from SEER and NCCR Diagnoses: 2003-2013
Age-adjustment by ICCC standards
Follow-up until Dec 31, 2013
Presumed-Alive assumption
N=10,076 first primaries of CRC in Nevada
Cause-specific survival
Nevada data: no National Linkage
Life Tables Method and Cox Regression

18. SURVIVAL BY AJCC STAGE AT DIAGNOSIS
MEN
WOMEN

19. SURVIVAL BY REGION

20. Risk of Death Colorectal Cancer Nevada 2003-2013 Cox Proportional Hazards Model
HR*
(95% CI)
AJCC Stage I
1,711 1 II
2,047
2.2
III
2,407
4.0 IV
1,766
14.5
Race/Ethnicity: NH-White
7,495
NH-Black
737
0.88
Hispanic
928
0.83
Asian Pacific Islander
618
0.77
American Indian 66
0.92
Region: North – Reno
2,304
South – Las Vegas
7,038
1.12
Rural
734
0.98
*Adjusted for age, gender, year of diagnosis, sublocation (right colon, sigmoid, rectum, NOS) , grade of tumor, insurance type, SES

21. Reasons for North-South Gap?
Lower screening in South
2015, 61% VS 73%
Low Number of general & family practice physicians
22 vs 31 (US) per 100,000
Low Number of Medical Doctors
216 vs 327 (US) per 100,000
Washoe at 336 per 100,000
Clark County: only 65% of the US average number of physical specialists
Lack of a LV-based MD School of Medicine:
research activity, teaching status, clinical trials, etc.

22. Treatment for Colorectal Cancer
Stage
Treatment
POLIPECTOMY (during colonoscopy) I
SURGERY II
SURGERY with/without ADJUVANT CHEMOTHERAPY, RADIOTHERAPY (for rectal cancer)
III
SURGERY with ADJUVANT CHEMOTHERAPY, and RADIOTHERAPY (for rectal cancer) IV
COMBINATIONS (SURGERY, CHEMO, RADIO)
Source: cancer.net ASCO

23. Conclusions 1-Incidence in NV (risk) is average
2-Mortality in NV is high
3-Unfavorable stage distribution, lower rates of screening, low survival by stage in Clark County drive the state’s numbers
FOCUS:
i)-Increase Screening (will affect stage distribution)
ii)-Improve Quality of Care (will improve survival)

24.
THANK YOU