Cancers and
Amyotrophic Lateral Sclerosis in
Livingston County, IL
Peter P. Moschovis
and Leslie Stayner, PhD
University of Illinois at Chicago
May 11, 2006
Background
• The Livingston County
Environmental
Association approached
the University of Illinois at
Chicago School of Public
Health Division of
Epidemiology, requesting
expertise in addressing
some public health
concerns
Concerns Raised by Community
• Concern that exposures from landfill may
be causing an excess of:
– Cancers
•
•
•
•
•
Soft tissue sarcomas
Cutaneous T-cell lymphomas
Brain cancer
Breast cancer
Leukemia
– ALS (Lou Gehrig’s Disease)
From: Waller Regul Toxicol Pharmacol. 2000 Oct;32(2):174-83.
Childhood Leukemia - Woburn Massachusetts
Texas Sharp Shooter
X X
X XX X
X XX X XX X
X XX X
X X
Multiple Comparison Problem
• The more you look the more you are likely
to find something!
• Statistical tests that we use are designed
to detect an excess 5 out 100 times in
situations where there really isn’t a
problem
Caveat Emptor (warning)
• Because of these and other issues the
findings from these analyses should be
viewed as preliminary, and not be viewed
as providing definitive evidence that living
in Livingston County or near the landfill is
hazardous to your health!
What is epidemiology?
• “The study of how disease is distributed in
populations and of the factors that
influence or determine this distribution”
– Leon Gordis, Johns Hopkins University
• Or, more simply, the study of who gets sick
and why
Some basic statistical terms
• Incidence Rate =
(absolute risk)
# of new cases observed
total population being observed per unit time
• Relative Risk or Rate Ratio (RR)
RR =
rate in Livingston County
rate in reference population (Illinois)
A RR > 1 signifies an excess risk; a RR < 1 signifies a lower risk
• 95% Confidence Interval:
– A range of values that is 95% likely to contain the true value of the
population parameter; we are 95% sure that the true value of the
relative risk lies between these two numbers.
• p value:
– The probability of obtaining a finding at least as "impressive" as that
obtained by chance alone.
– The higher the p value, the higher the probability that the finding is the
result of chance.
Questions?
Questions to address
• What is the absolute risk of death by cancer type in
Livingston County?
• What is the relative risk of death by cancer type,
comparing Livingston County to the state of Illinois?
• What are the most common cancers in Livingston
county?
• What do we know about the risk factors for those
cancers?
• What is the risk of dying of ALS in Livingston County?
• Does this rate differ significantly from the rate for Illinois
or the U.S. as a whole?
Our Strategy
• Briefed by LCEA
• Interviewed local physicians
• Obtained publicly available data from the
Illinois Dept. of Public Health and the
Centers for Disease Control and
Prevention
• Analyzed it in SAS (statistics program)
What do we know about cancer?
•
•
It develops when cells in a part of
the body begin to grow out of
control.
It’s very common
– Lifetime risk of developing cancer
is 1 in 2 for men, 1 in 3 for women
•
Not one single disease
– Lung cancer ≠ breast cancer ≠
colon cancer ≠ muscle cancer
•
Adenocarcinoma of the colon
Not even cancers in the same site
are the same
– E.g., “lung cancer”:
Adenocarcinoma of the lung ≠
mesothelioma ≠ small cell
carcinoma of the lung
•
Different cancer types have
different risk factors, prognoses,
and therapies
Rhabdomyosarcoma
Sources: American Cancer Society, ACS Statistics; Kumar, et al. Robbins and Cotran: Pathologic Basis of Disease,
7th ed., Copyright © 2005 Saunders
Leading causes of death, 2003
Rank
Cause of Death
No. of
deaths
% of all
deaths
1.
Heart Diseases
685,089
28.0
2.
Cancer
556,902
22.7
3.
Cerebrovascular diseases
157,689
6.4
4.
Chronic lower respiratory diseases
126,382
5.2
5.
Accidents (Unintentional injuries)
109,277
4.5
6.
Diabetes mellitus
74,219
3.0
7.
Influenza and pneumonia
65,163
2.7
8.
Alzheimer disease
63,457
2.6
9.
Nephritis
42,453
1.7
10.
Septicemia
34,069
1.4
Source: US Mortality Public Use Data Tape 2003, National Center for Health Statistics, Centers for Disease Control
and Prevention, 2006.
Lifetime Probability of Developing Cancer, by Site, Men,
2000-2002*
Site
Risk
All sites†
1 in 2
Prostate
1 in 6
Lung and bronchus
1 in 13
Colon and rectum
1 in 17
Urinary bladder‡
1 in 28
Non-Hodgkin lymphoma
1 in 46
Melanoma
1 in 52
Kidney
1 in 64
Leukemia
1 in 67
Oral Cavity
1 in 73
Stomach
1 in 82
* 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
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, Women, US,
2000-2002*
Site
Risk
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
* 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
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
Major chemical carcinogens
•
Direct-Acting Carcinogens
– Alkylating Agents
•
•
•
•
β-Propiolactone
Dimethyl sulfate
Diepoxybutane
Anticancer drugs
(cyclophosphamide, chlorambucil,
nitrosoureas, and others)
TABLE 7-11
-- MajorAgents
Chemical Carcinogens
– Acylating
• 1-Acetyl-imidazole
• Dimethylcarbamyl chloride
•
Procarcinogens That Require
Metabolic Activation
– Polycyclic and Heterocyclic
Aromatic Hydrocarbons
•
•
•
•
•
Benz(a)anthracene
Benzo(a)pyrene
Dibenz(a,h)anthracene
3-Methylcholanthrene
7,12-Dimethylbenz(a)anthracene
Aromatic Amines, Amides, Azo Dyes
2-Naphthylamine (β-naphthylamine)
Benzidine
2-Acetylaminofluorene
Dimethylaminoazobenzene (butter
yellow)
Natural Plant and Microbial Products
Aflatoxin B1
Griseofulvin
Cycasin
Safrole
Betel nuts
Others
Nitrosamine and amides
Vinyl chloride, nickel, chromium
Insecticides, fungicides
Polychlorinated biphenyls
Source: Kumar, et al. Robbins and Cotran: Pathologic Basis of Disease, 7th ed., Copyright © 2005 Saunders
Our findings: cancer
Cancer
• During the period 1988 – 2002
– 825,196 cases of cancer were reported in Illinois
– 3,045 cases of cancer were reported in Livingston
County
• For cancer as a whole during this period,
comparing Livingston County to Illinois
– The crude RR is 1.12 [1.076, 1.156], p < 0.001
– Adjusting for age, sex, and race,
the adjusted RR is 0.963 [0.930, 0.998], p = 0.0391
Age Distribution of the Population
Percent of Total Population
35%
Livingston County
30%
Illinois
25%
20%
15%
10%
5%
0%
<5
5-14
15-34
35-44
45-54
55-64
Age
Median age for Livingston County: 37.3
Median age for Illinois: 34.7
65-74
75 +
Comparing Livingston County to Illinois:
All Cancers by Age
Rate of Cancer per 100,000
3000
Livingston County
2500
Illinois
20
15
2000
10
1500
5
1000
0
<5
500
5-14
0
<5
5-14
15-34
35-44
Age
45-54
55-64
65-74
75 +
Comparing Livingston County to Illinois:
Cancers by Sex, Race
97.2
Percent of Cancers
100.0
90.0
Livingston County
80.0
Illinois
85.6
70.0
60.0
50.0
49.7 49.3
50.3 50.7
40.0
30.0
14.4
20.0
10.0
2.8
0.0
male
female
white
nonwhite
What about the individual
cancer types?
Livingston County
Cases
Cases per
100,000
Illinois
Cases per
Cases 100,000 Crude RR
Adjusted
RR (MH)
95% CI
p
Lung
457
76.87
121758
67.75
1.13
0.98
(0.89, 1.07)
0.64
breast-invasive
424
71.31
123143
68.52
1.04
0.91
(0.83, 1.01)
0.06
prostate
378
63.58
110890
61.71
1.03
0.89
(0.81, 0.99)
0.03
colorectal
368
61.90
102729
57.16
1.08
0.90
(0.81, 0.99)
0.04
all other sites
281
47.26
75342
41.92
1.13
0.99
(0.88, 1.11)
0.87
bladder
181
30.44
36489
20.30
1.50
1.17
(1.01, 1.36)
0.03
NHL
114
19.17
30662
17.06
1.12
0.93
(0.77, 1.11)
0.41
leukemias
112
18.84
20701
11.52
1.64
1.37
(1.14, 1.65)
0.001
endometrial
96
16.15
23688
13.18
1.22
1.04
(0.85, 1.27)
0.68
melanoma
81
13.62
17067
9.50
1.43
1.19
(0.96, 1.48)
0.12
kidney
67
11.27
20323
11.31
1.00
0.86
(0.68, 1.09)
0.21
oral cavity
66
11.10
18310
10.19
1.09
1.00
(0.79, 1.27)
1.00
pancreas
58
9.76
19005
10.58
0.92
0.79
(0.61, 1.02)
0.07
ovary
58
9.76
13962
7.77
1.26
1.08
(0.83, 1.40)
0.57
breast - in situ
49
8.24
19618
10.92
0.75
0.68
(0.52, 0.90)
0.007
myelomas
46
7.74
9464
5.27
1.47
1.38
(1.03, 1.84)
0.03
stomach
43
7.23
14353
7.99
0.91
0.83
(0.61, 1.12)
0.22
nervous system
41
6.90
11134
6.20
1.11
0.97
(0.71, 1.32)
0.84
cervix - invasive
35
5.89
10532
5.86
1.00
1.09
(0.78, 1.52)
0.60
esophagus
29
4.88
9036
5.03
0.97
0.92
(0.64, 1.32)
0.65
Hodgkin’s lymphomas
21
3.53
5059
2.82
1.25
1.21
(0.79, 1.86)
0.38
testis
19
3.20
4374
2.43
1.31
1.25
(0.80, 1.96)
0.33
liver
11
1.85
6076
3.38
0.55
0.52
(0.29, 0.95)
0.03
Livingston County
Cases
Cases per
100,000
Illinois
Cases per
Cases 100,000 Crude RR
Adjusted
RR (MH)
95% CI
p
Lung
457
76.87
121758
67.75
1.13
0.98
(0.89, 1.07)
0.64
breast-invasive
424
71.31
123143
68.52
1.04
0.91
(0.83, 1.01)
0.06
prostate
378
63.58
110890
61.71
1.03
0.89
(0.81, 0.99)
0.03
colorectal
368
61.90
102729
57.16
1.08
0.90
(0.81, 0.99)
0.04
all other sites
281
47.26
75342
41.92
1.13
0.99
(0.88, 1.11)
0.87
bladder
181
30.44
36489
20.30
1.50
1.17
(1.01, 1.36)
0.03
NHL
114
19.17
30662
17.06
1.12
0.93
(0.77, 1.11)
0.41
leukemias
112
18.84
20701
11.52
1.64
1.37
(1.14, 1.65)
0.001
endometrial
96
16.15
23688
13.18
1.22
1.04
(0.85, 1.27)
0.68
melanoma
81
13.62
17067
9.50
1.43
1.19
(0.96, 1.48)
0.12
kidney
67
11.27
20323
11.31
1.00
0.86
(0.68, 1.09)
0.21
oral cavity
66
11.10
18310
10.19
1.09
1.00
(0.79, 1.27)
1.00
pancreas
58
9.76
19005
10.58
0.92
0.79
(0.61, 1.02)
0.07
ovary
58
9.76
13962
7.77
1.26
1.08
(0.83, 1.40)
0.57
breast - in situ
49
8.24
19618
10.92
0.75
0.68
(0.52, 0.90)
0.007
myelomas
46
7.74
9464
5.27
1.47
1.38
(1.03, 1.84)
0.03
stomach
43
7.23
14353
7.99
0.91
0.83
(0.61, 1.12)
0.22
nervous system
41
6.90
11134
6.20
1.11
0.97
(0.71, 1.32)
0.84
cervix - invasive
35
5.89
10532
5.86
1.00
1.09
(0.78, 1.52)
0.60
esophagus
29
4.88
9036
5.03
0.97
0.92
(0.64, 1.32)
0.65
Hodgkin’s lymphomas
21
3.53
5059
2.82
1.25
1.21
(0.79, 1.86)
0.38
testis
19
3.20
4374
2.43
1.31
1.25
(0.80, 1.96)
0.33
liver
11
1.85
6076
3.38
0.55
0.52
(0.29, 0.95)
0.03
Livingston County
Cases
Cases per
100,000
Illinois
Cases per
Cases 100,000 Crude RR
Adjusted
RR (MH)
95% CI
p
Lung
457
76.87
121758
67.75
1.13
0.98
(0.89, 1.07)
0.64
breast-invasive
424
71.31
123143
68.52
1.04
0.91
(0.83, 1.01)
0.06
prostate
378
63.58
110890
61.71
1.03
0.89
(0.81, 0.99)
0.03
colorectal
368
61.90
102729
57.16
1.08
0.90
(0.81, 0.99)
0.04
all other sites
281
47.26
75342
41.92
1.13
0.99
(0.88, 1.11)
0.87
bladder
181
30.44
36489
20.30
1.50
1.17
(1.01, 1.36)
0.03
NHL
114
19.17
30662
17.06
1.12
0.93
(0.77, 1.11)
0.41
leukemias
112
18.84
20701
11.52
1.64
1.37
(1.14, 1.65)
0.001
endometrial
96
16.15
23688
13.18
1.22
1.04
(0.85, 1.27)
0.68
melanoma
81
13.62
17067
9.50
1.43
1.19
(0.96, 1.48)
0.12
kidney
67
11.27
20323
11.31
1.00
0.86
(0.68, 1.09)
0.21
oral cavity
66
11.10
18310
10.19
1.09
1.00
(0.79, 1.27)
1.00
pancreas
58
9.76
19005
10.58
0.92
0.79
(0.61, 1.02)
0.07
ovary
58
9.76
13962
7.77
1.26
1.08
(0.83, 1.40)
0.57
breast - in situ
49
8.24
19618
10.92
0.75
0.68
(0.52, 0.90)
0.007
myelomas
46
7.74
9464
5.27
1.47
1.38
(1.03, 1.84)
0.03
stomach
43
7.23
14353
7.99
0.91
0.83
(0.61, 1.12)
0.22
nervous system
41
6.90
11134
6.20
1.11
0.97
(0.71, 1.32)
0.84
cervix - invasive
35
5.89
10532
5.86
1.00
1.09
(0.78, 1.52)
0.60
esophagus
29
4.88
9036
5.03
0.97
0.92
(0.64, 1.32)
0.65
Hodgkin’s lymphomas
21
3.53
5059
2.82
1.25
1.21
(0.79, 1.86)
0.38
testis
19
3.20
4374
2.43
1.31
1.25
(0.80, 1.96)
0.33
liver
11
1.85
6076
3.38
0.55
0.52
(0.29, 0.95)
0.03
Age, Sex, and Race-Adjusted Relative Risk
0.00
Lung
breast-invasive
prostate
colorectal
all other sites
bladder
NHL
leukemias
endometrial
melanoma
kidney
oral cavity
pancreas
ovary
breast - in situ
myelomas
stomach
nervous system
cervix - invasive
esophagus
Hodgkin’s lymphomas
testis
liver
bone
0.50
1.00
1.50
2.00
2.50
3.00
3.50
4.00
The most common cancers
•
•
•
•
Lung
Breast
Prostate
Colon
Lung Cancer
•
Incidence
–
•
The average annual incidence over the fifteen year period studied
was 30.5 cases per year, making lung cancer the most common
cancer diagnosed in Livingston County.
Relative Risk
–
–
•
•
Compared to the rest of Illinois, residents of Livingston County were
equally likely to be diagnosed with lung cancer
Adjusted RR = 0.94 [0.89, 1.07], p = 0.64
Highest risk groups: men, people age 65 and older
Established risk factors:
–
–
–
–
–
–
Smoking (including secondhand smoke)
Radon
Silica
Cadmium, hexavalent chromium
Formaldehyde
Asbestos
Breast Cancer
•
Incidence: most common cancer among women in
Livingston County
–
–
•
Invasive breast cancer = 28.3 cases per year
Breast cancer in situ = 3.3 cases per year
Relative Risk
–
–
•
Compared to the rest of Illinois, residents of Livingston
County were marginally less likely to be diagnosed with
invasive breast cancer
Adjusted RR = 0.91 [0.83, 1.01], p = 0.06
Highest risk groups:
–
–
–
Women
Invasive: age 75 and older
In situ: ages 45 – 64
Breast Cancer
•
Established risk factors:
–
Age: 77% of cases occur in women over 50 years of age, with
an average age at diagnosis of 64 years.
–
Age at menarche: women who reach menarche before age 11
have a 20% increased risk of breast cancer compared with their
counterparts who reach menarche after age 14.
–
Late first live birth: women who deliver their first child younger
than age 20 have half the risk of nulliparous women or those
whose first live birth is after age 35
–
Family history (first-degree relatives with breast cancer): risk
increases with the number of affected first-degree relatives
(mother, sister, or daughter).
–
History of abnormal breast biopsies: previous breast biopsies
with atypical hyperplasia increase the risk of breast cancer.
–
Race: black women have an overall lower incidence than white
women, but tend to present at a more advanced stage and have
increased mortality.
Source: National Cancer Institute, http://www.cancer.gov/bcrisktool/.
Prostate Cancer
•
Incidence:
–
•
The average annual incidence over the fifteen year period studied
was 25.2 cases per year.
Relative Risk:
–
–
•
Compared to the rest of Illinois, men in Livingston County were 11%
less likely to develop prostate cancer
Adjusted RR = 0.89 [0.81, 0.99], p = 0.03
Highest risk groups
–
–
•
Men age 65 -74 and older than 75
White race
Established risk factors:
–
–
–
Older age (75% of men over 85 have latest prostate cancer)
Family history, ethnic origin (W>B>Asians)
High intake of α-linolenic acid (a polyunsaturated fatty acid in
vegetables and dairy products) and calcium
Source: H. Grönberg. “Prostate cancer epidemiology.” Lancet. 2003 Mar 8;361(9360):859-64.
Colorectal Cancer
•
Incidence:
–
•
The average annual incidence over the fifteen year period
studied was 24.5 cases per year.
Relative Risk:
–
–
•
Compared to the rest of Illinois, residents of Livingston County
were 10% less likely to be diagnosed with colorectal cancer
Adjusted RR = 0.90 [0.81, 0.99], p = 0.04
Highest risk groups:
–
–
–
•
Age greater than 75
M=F
W>B
Established risk factors:
–
–
Dietary factors: high calorie, low fiber, refined carbohydrates,
red meat
Family history
Source: Kumar, et al. Robbins and Cotran: Pathologic Basis of Disease, 7th ed., Copyright © 2005 Saunders
What you can do about these
common cancers
• Lung cancer: stop smoking
• Breast cancer: get a screening mammogram
– Women age 40 and older: should be screened
every one to two years with mammography.
– Women who are at higher than average risk of
breast cancer should seek expert medical advice
about whether they should begin screening before
age 40 and the frequency of screening.
• Prostate cancer: get a digital rectal exam, PSA?
• Colorectal cancer: get a screening colonoscopy
after age 50
Source: USPSTF, National Cancer Institute
Cancers with elevated rates in
Livingston County
•
•
•
•
Bladder
Leukemia
Myeloma
Bone
Bladder Cancer
•
Incidence:
–
•
The average annual incidence over the fifteen year
period studied was 12.1 cases per year.
Relative Risk:
–
–
•
Compared to the rest of Illinois, residents of
Livingston County were 17% more likely to be
diagnosed with bladder cancer.
Adjusted RR = 1.17 [1.01, 1.36], p = 0.03
Highest risk groups:
–
–
Age greater than 75
M>>F (RR = 2.9)
Bladder Cancer
•
Established risk factors:
–
–
–
–
–
–
Cigarette smoking (50-80% of cases among
men are associated with smoking)
Industrial exposure to aryl amine dyes
Schistosoma haematobium infections
Long-term use of analgesics
Long-term exposure to cyclophosphamide
History of exposure to radiation
Source: Kumar, et al. Robbins and Cotran: Pathologic Basis of Disease, 7th ed., Copyright © 2005 Saunders
Leukemia
•
Incidence:
–
•
The average annual incidence over the fifteen year period
studied was 7.5 cases per year.
Relative Risk:
–
Compared to the rest of Illinois, residents of Livingston County
were 37% more likely to be diagnosed with leukemia.
Adjusted RR = 1.37 [1.14, 1.65], p = 0.001
–
•
Highest risk groups:
–
While there is a small peak in very young children ( age <5),
the preponderance of cases are in those greater than age 75.
Excess cases appear to cluster in two groups
–
•
•
Age 55 – 64: RR = 2.41 [1.61, 3.60]
Age 75+: RR = 1.40 [1.05, 1.883]
Leukemia
• Established risk factors:
– Prior chemotherapy or radiotherapy for
cancer, radiation exposure
– Benzene (AML), ethylene oxide
– Immunosuppression
– HTLV-1, EBV (ALL)
– Smoking (AML)
Source: American Cancer Society
Myeloma
•
Incidence:
–
•
The average annual incidence over the fifteen year period
studied was 3.1 cases per year.
Relative Risk:
–
–
•
Compared to the rest of Illinois, residents of Livingston County
were 38% more likely to be diagnosed with myeloma.
Adjusted RR = 1.38 [1.03, 1.84], p = 0.03
Highest risk groups:
–
–
•
Older age (risk increases with each age group)
M=F
Established risk factors:
–
–
Radiation exposure (atomic bomb survivors, nuclear plant
workers)
Occupational exposures (herbicides and insecticides, organic
solvents)
Source: Abeloff, Clinical Oncology, 3rd ed., Copyright © 2004 Churchill Livingstone
Bone Cancer
•
Incidence:
–
•
The average annual incidence over the fifteen year
period studied was 0.7 cases per year.
Relative Risk:
–
–
•
Compared to the rest of Illinois, residents of
Livingston County were almost twice as likely to be
diagnosed with bone cancer.
Adjusted RR = 1.91 [1.03, 3.56], p = 0.04
Highest risk groups:
–
–
Ages 15 – 34, smaller second peak between ages
65 - 74
M≈F
Osteosarcoma
• Most common primary
malignant tumor of bone
• Has a bimodal age
distribution
– 75% occur in patients
younger than age 20
– Smaller second peak
occurs in the elderly, who
frequently suffer from
conditions known to be
associated with the
development of
osteosarcoma—Paget
disease, bone infarcts, and
prior irradiation.
• M > F (1.6:1)
Source: Kumar, et al. Robbins and Cotran: Pathologic Basis of Disease, 7th ed., Copyright © 2005 Saunders
Ewing Sarcoma
• Second most common
group of bone sarcomas
in children
• Most patients are 10 to
15 years old, and
approximately 80% are
younger than age 20
years.
• Boys are affected slightly
more frequently than girls
• W>>B
Source: Kumar, et al. Robbins and Cotran: Pathologic Basis of Disease, 7th ed., Copyright © 2005 Saunders
Bone Cancer
•
Risk Factors for
Osteosarcoma
a) previous osseous disease
(Paget's disease)
b) familial-genetic factors
(hereditary retinoblastoma, LiFraumeni syndrome,
Rothmund-Thompson
syndrome, Bloom syndrome,
familial OS, DiamondBlackfan anemia)
c) antineoplastic drugs
d) ionizing radiation (radium dial
workers)
e) biologic factors
f) parental occupation
(conflicting data)
g) other factors (artificial
osseous implants and
trauma)
Risk Factors for Ewing Sarcoma
ethnic-cultural (Caucasian race)
genetic factors
parental occupation (herbicide,
pesticide and fertilizer
exposure)
maternal obstetric history
other factors (parental smoking)
Source: Ferris, et al. Annales de Pediatrica (Barc). 2005 Dec;63(6):537-47.
What about the other rare cancers?
• Cutaneous T-cell lymphoma
– Part of non-Hodgkin’s lymphoma, which had an
overall adjusted RR = 0.93 [0.77, 1.11], p=0.41
• Soft tissue sarcomas
– Part of “all other types,” which had an overall adjusted
RR = 0.99 [0.88, 1.11], p = 0.87
• Bottom line: we can’t measure rare cancers
using publicly available data
Our findings: ALS
ALS Epidemiology
• Prevalence: 7 per 100,000 people worldwide
• Incidence: closely approximated by mortality rate
– Estimates range from 0.07 (Mexico) to more than 60
per 100,000 per year (Guam in 1950s).
– Median survival: 19 months from diagnosis
– 5-year survival after diagnosis is only 7%
• 3 forms of ALS
– Sporadic (90%)
– Familial (9%)
– Geographic clusters (1%): Guam, South Pacific
Established Risk Factors
•
•
•
•
Age
Sex
Genes: superoxide dismutase
Not much else with strong association, though many
exposures have been studied
–
–
–
–
–
–
–
BMAA (toxin in cycads in Guam)
Antioxidant vitamins shown to have mild protective effect
Smoking
Brain trauma
Metals, agricultural chemicals
Military Service
EMF
• “After all these years, we really don’t know much about
ALS.”
- Jacob Brody, UIC
ALS Case List for Livingston County:
1979 - 2002
Case #
Year of Dx
Age
Gender
Race
1
1980
(suppressed)
F
White
2
1981
(suppressed)
M
White
3
1983
(suppressed)
M
White
4
1984
(suppressed)
F
White
5
1987
(suppressed)
F
White
6
1988
(suppressed)
F
White
7
1988
(suppressed)
F
White
8
1990
(suppressed)
M
White
9
1991
(suppressed)
F
White
10
1994
(suppressed)
F
White
11
1995
(suppressed)
F
White
12
1996
(suppressed)
F
White
13
1998
(suppressed)
F
White
14
1999
(suppressed)
F
White
15
1999
(suppressed)
F
White
16
2001
(suppressed)
F
White
17
2002
(suppressed)
M
White
18
2002
(suppressed)
M
White
Source: CDC Compressed Mortality File, http://wonder.cdc.gov
Livingston County ALS Rates
1979 - 2002
Age
Total
Population
Deaths
Crude
Death Rate
Ageadjusted
Rate
Under 1 Year
0
12,803
0.000
0.000
1- 4 years
0
51,622
0.000
0.000
5- 9 years
0
66,741
0.000
0.000
10-14 years
0
69,321
0.000
0.000
15-19 years
0
70,592
0.000
0.000
20-24 years
0
68,394
0.000
0.000
25-34 years
0
150,866
0.000
0.000
35-44 years
0
134,579
0.000
0.000
45-54 years
4
103,079
3.881
0.391
55-64 years
3
86,756
3.458
0.293
65-74 years
5
74,684
6.695
0.485
75-84 years
4
49,520
8.078
0.325
85 years and over
2
21,433
9.331
0.113
Total
18
960,390
Source: CDC Compressed Mortality File, http://wonder.cdc.gov
1.874
1.607
Illinois ALS Rates
1979 - 2002
Age
Total
Population
Deaths
Crude
Death Rate
Ageadjusted
Rate
Under 1 Year
0
4,439,974
0.000
0.000
1- 4 years
2
16,869,376
0.012
0.001
5- 9 years
1
20,562,923
0.005
0.000
10-14 years
2
20,681,468
0.010
0.001
15-19 years
2
21,433,868
0.009
0.001
20-24 years
1
22,024,987
0.005
0.000
25-34 years
30
46,184,928
0.065
0.011
35-44 years
144
40,634,278
0.354
0.053
45-54 years
381
31,032,738
1.228
0.124
55-64 years
917
24,666,368
3.718
0.315
65-74 years
1,359
19,128,705
7.105
0.515
75-84 years
955
11,248,764
8.490
0.341
85 years and over
175
3,679,116
4.757
0.058
3,969
282,587,493
1.405
1.420
Total
Source: CDC Compressed Mortality File, http://wonder.cdc.gov
United States ALS Rates
1979 - 2002
Age
Total
Population
Deaths
Crude
Death Rate
Ageadjusted
Rate
Under 1 Year
16
92,968,035
0.017
0.000
1- 4 years
14
353,534,207
0.004
0.000
5- 9 years
14
438,647,368
0.003
0.000
10-14 years
12
443,234,740
0.003
0.000
15-19 years
33
459,431,791
0.007
0.001
20-24 years
81
474,938,058
0.017
0.001
25-34 years
717
985,814,683
0.073
0.013
35-44 years
3,182
890,335,256
0.357
0.054
45-54 years
8,569
676,935,773
1.266
0.127
55-64 years
19,382
533,322,526
3.634
0.308
65-74 years
31,940
423,559,264
7.541
0.547
75-84 years
22,605
244,562,320
9.243
0.372
4,369
77,757,259
5.619
0.068
90,934
6,095,041,280
1.492
1.491
85 years and over
Total
Source: CDC Compressed Mortality File, http://wonder.cdc.gov
Relative Rates (IL, US)
• Livingston County vs. Illinois
– Adjusted RR = 1.1316 [0.6550, 1.9551]
– p = 0.6574
• Livingston County vs. USA
– Adjusted RR = 1.0778 [0.6243, 1.8605]
– p = 0.7880
• No significant difference between ALS rates in
Livingston County and Illinois or the USA
Conclusions
• The 4 most common cancers comprise 55% of all
cancers in Livingston County:
– Lung, breast, prostate, colon
• Some cancers are equally common in Livingston County
and the state
– Lung, NHL, HL, endometrial, melanoma, kidney, oral cavity,
pancreas, ovarian, stomach, CNS, cervical, esophageal,
testicular
• Some cancers are less common than the state
– Breast invasive and in situ, liver, prostate, colorectal
• Some cancers are more common than the state
– Bladder, leukemia, myeloma, bone
• ALS appears to be equally common in Livingston
County, the State, and the US as a whole
Discussion
• Take-home messages
– Prevention of common cancers is the most
effect method of reducing cancer in Livingston
County.
– There does not appear to be a general excess
of cancer or ALS in Livingston County,
although some specific cancers do appear to
have moderately elevated rates.
Discussion
• Limitations of study
– Limited number of cancer categories does not allow
the detection of differences in rare cancers
– Lack of address information makes a true cluster
investigation impossible
– Incomplete ascertainment of cancer cases for
Livingston natives living elsewhere during diagnosis
– Small population gives relatively low power to detect
subtle differences
What are the next steps?
• Consider requesting further analysis of
specific cancer types by IDPH.
• Look at landfills across the country to see
if those who live near them have elevated
rates of disease
– Currently doing a study assessing the
relationship between Superfund sites and ALS
rates
Thank you!
• Acknowledgments
–
–
–
–
–
Carolyn Gerwin
The LCEA
City of Pontiac
IDPH
CDC