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Screening for increased cancer risk near toxic waste sites Recinda Sherman, MPH CTR Florida Cancer Data Systems NAACCR Annual Meeting, June 2008 Background: 2 Cluster detection & surveillance • Routine surveillance versus reactive cluster investigations – No a priori assumptions of boundary location • Ho = even distribution of dx by geography – Increases likelihood of identifying a true cluster • Targeted prevention activities – Cluster concern response more thorough, timely, consistent and scientific • Active versus Passive – Rapid intervention 3 Cluster detection & surveillance • Develop new cluster detection surveillance model for Florida – Investigate technology • SaTScan, ClusterSEER – Quantify methodological limitations – Systematic framework for identifying communities at risk 4 Disparities in breast cancer • Entire cancer continuum • Education, Poverty – Race/ethnicity surrogate? • Geography – Pacific NW, Marin County, Long Island – Demographic driven? 5 Risk factors for breast cancer • Immutable – Age, sex, genetics • Modifiable – Hormone replacement – Motherhood • Age, parity, breastfeeding – Alcohol use – Obesity/Physical activity Environmental ?? 6 Methods: 7 Florida Cancer Data Systems • Inception date 1981 – 1981 Hospital data – 1995 CDC-NPCR enhancement • Physician office, death certificates, freestanding radiation, pathology • 2nd largest in nation – 95,000 incidence cases per year • Operated by University of Miami Miller Medical School – Under DOH contract • NAACCR Gold 8 Florida breast cancer data • 1998-2002 – Straddle census 2000 • 77,729 cases • 88% geocoded – 70% exact street level match – 5% imprecise street level match – 8% bg/tract centroid/st intersection – 3% zipcode centroid Environmental data • EPA NPL sites – National priorities among the known releases or threatened releases of hazardous substances, – Guide EPA in determining which warrant further investigation • 39 NPL Sites – Potential breast cancer carcinogens • benzene, cadmium, chromium, polycyclic aromatic hydrocarbons (PAHs), pesticides, and vinyl chloride 10 Focused test • Lawson & Waller Test – ClusterSEER • Detect clustering around a suspected point source – Evaluates the pattern of disease frequency the closer to a specific location – Multiple geographic areas scored for difference between the O/E and weighted by distance from the point of interest 11 Results: 12 13 Hazard scores • Hazard ranking system – Used to place waste sites on NPL – Assess potential for threat to human health or environment • Hazard score for sites with identified clusters higher – 43.99 versus 45.99 – range 30.19-59.81 14 Potential carcinogens 15 Potential exposure routes 16 Income gradient Table 3. Distance from sites with identified clustering Household Income Median Mean 5 Miles 40,684 52,070 3 Miles 34,607 43,019 1 Mile 30,392 37,865 Florida Average 42,111 53,547 17 EPA assessments • Public health assessment • Health consultation – Conducted when there is a specific exposure question – None of the sites with statistically higher risk had a health consultation performed – This may indicate low levels of advocacy concerning these sites 18 Methodological limitations Registry Implications: 20 Future Focus • Proactive surveillance by registry – “Screening” tool for areas for further focus/epi investigation – Hypothesis generating • Collaboration between Registry and Environmental Health, others • Community partnership 21 Data, data everywhere & not a thought to think • Underlying demographics – Artifact? Residential Segregation? Contagion? – Primary assumption – denominator problem • Rule out • Release of cluster data – Communicate Risk – Prioritize – Ability to follow up with intervention • External partners 22 Questions? Thank you to our funders: Thank you to my colleagues: • Dr. David Lee – UM, Miami, FL • Dr. Greg Kearny – FL DOH, Tallahassee, FL • D. Jennifer Hu – UM, Miami, FL • Dr. Geoffrey Jacquez – TerraSEER, Inc, Ann Arbor, MI • Dr. Lora Fleming – UM, Miami, FL 23