Disparities in Colorectal Cancer Disparities in Colorectal Cancer Incidence, USA 1998-2003:Incidence, USA 1998-2003:An Updated NPCR/SEER An Updated NPCR/SEER

Data AnalysisData AnalysisSun Hee Rim MPHSun Hee Rim MPH

Laura Seeff MDLaura Seeff MDFaruque Ahmed MD PhDFaruque Ahmed MD PhD

Jessica King MPHJessica King MPHSteven Coughlin PhDSteven Coughlin PhD

American American Cancer Society Cancer Disparities Conference Cancer Society Cancer Disparities Conference April 18-20, 2007April 18-20, 2007

Division of Cancer Prevention and Control,

Center for Disease Control and Prevention, Atlanta, Georgia

DisclaimerDisclaimer

The findings and conclusions in The findings and conclusions in this report are those of the authors this report are those of the authors and do not necessarily represent and do not necessarily represent

the views of the Center for the views of the Center for Disease Control and Prevention.Disease Control and Prevention.

Background on Colorectal CancerBackground on Colorectal Cancer

Second leading cause of cancer deaths in Second leading cause of cancer deaths in the USAthe USA

Burden of disease is high but unequal Burden of disease is high but unequal across subpopulationsacross subpopulations

Screening = prevention & early detectionScreening = prevention & early detection

5-year relative survival rate for localized 5-year relative survival rate for localized colorectal cancer is 90%colorectal cancer is 90%

Colorectal Cancer in African AmericansColorectal Cancer in African Americans

Higher CRC incidenceHigher CRC incidence

Younger average age at diagnosisYounger average age at diagnosis Higher proportion present disease at Higher proportion present disease at

age<50 yearsage<50 years

More proximal diseaseMore proximal disease

SEER dataSEER data

Current Screening GuidelinesCurrent Screening Guidelines

National GuidelinesNational Guidelines U.S. Preventive Services U.S. Preventive Services

Task ForceTask Force American Cancer Society American Cancer Society U.S. Multi-society Task U.S. Multi-society Task

Force on CRC Screening Force on CRC Screening

Recommended for all average risk persons regardless of race/ethnicity and sex

Screening Test

Frequency

FOBT (at-home) Annually, guaiac-based or immunochemical

Flexible Sigmoidoscopy

Every 5 years

Combination: FOBT & Flex Sig

FOBT annually and Flex Sig every 5 years

DCBE Every 5 years

Colonoscopy Every 10 years

Tailored Screening Guidelines?Tailored Screening Guidelines?

Should screening guidelines take into Should screening guidelines take into account burden by demographic account burden by demographic subgroups?subgroups?Suggested modification of CRC guidelines Suggested modification of CRC guidelines for African Americans by American for African Americans by American College of GastroenterologyCollege of Gastroenterology Beginning age 45 Beginning age 45 Colonoscopy rather than flexible Colonoscopy rather than flexible

sigmoidoscopysigmoidoscopy

Objective Objective

To describe the most current burden To describe the most current burden of CRC of CRC Updated, nationally representative Updated, nationally representative

NPCR/SEER cancer surveillance dataNPCR/SEER cancer surveillance data By subpopulationsBy subpopulations

Current analysisCurrent analysis African Americans compared to whites African Americans compared to whites Age 45-49 and ≥ 50 years Age 45-49 and ≥ 50 years Incidence rates by sub-site and stage Incidence rates by sub-site and stage

CDC’s National Program of Cancer Registries (NPCR) and CDC’s National Program of Cancer Registries (NPCR) and NCI’s Surveillance, Epidemiology, and End Result (SEER)NCI’s Surveillance, Epidemiology, and End Result (SEER)

Slide courtesy of Cancer Surveillance Branch, DCPC, CDChttp://apps.nccd.cdc.gov/cancercontacts/npcr/contacts.asp

MethodsMethodsIncidence rates (IR) were age-adjusted by the Incidence rates (IR) were age-adjusted by the Direct Method to the 2000 U.S. standard Direct Method to the 2000 U.S. standard populationpopulation 95% CI and p-values were calculated95% CI and p-values were calculated

Rate Ratio (RR) was defined as the ratio of the Rate Ratio (RR) was defined as the ratio of the age-adjusted incidence ratesage-adjusted incidence rates Rate Ratio = (IRRate Ratio = (IRAfrican AmericansAfrican Americans)/(IR)/(IRWhitesWhites))

Rate Difference (RD) measured the difference Rate Difference (RD) measured the difference between the rates (per 100,000 population)between the rates (per 100,000 population) Rate Difference = (IRRate Difference = (IRAfrican AmericansAfrican Americans)-(IR)-(IRWhitesWhites))

Definition of Stage & Sub-siteDefinition of Stage & Sub-site

Stage at Stage at DiagnosisDiagnosis

Early Early localized cancerslocalized cancers

LateLatemetastasized cancersmetastasized cancers

Anatomic Anatomic SubsitesSubsites

Right: Proximal colonRight: Proximal coloncecum, ascending colon, hepatic flexure, cecum, ascending colon, hepatic flexure,

transverse colon, splenic flexuretransverse colon, splenic flexure

Left: Distal colon + RectumLeft: Distal colon + RectumDistal: descending colon and sigmoid colonDistal: descending colon and sigmoid colon

Rectum: rectosigmoid junction and rectum not Rectum: rectosigmoid junction and rectum not otherwise specifiedotherwise specified

Diagram of the ColonDiagram of the ColonSplenic flexure

Hepatic Flexure

Right Colon(Proximal)

Left Colon(Distal Colon + Rectum)

Burden of DiseaseBurden of DiseaseInvasive CRC by Selected Features,Invasive CRC by Selected Features,

United States, 1998-2003United States, 1998-2003

Sex Number (%)Age-adjusted

Incidence Rates

n = 750,252 (per 100,000)

MaleMale 380,890 (51%)380,890 (51%) 63.063.0

FemaleFemale 369,362 (49%)369,362 (49%) 45.545.5

Age

< 45 yrs 31,906 (4%) 3.5

45-49 yrs 28,643 (4%) 28.1

50-64 yrs 175,990 (24%) 82.3

≥ 65 yrs 513,713 (68%) 287.8

Invasive CRC by Selected Features,Invasive CRC by Selected Features,United States, 1998-2003United States, 1998-2003

Race Number Age-adjusted

Incidence Rates

WhiteWhite 655,491 (87%)655,491 (87%) 52.452.4

African AmericansAfrican Americans 66,233 (9%)66,233 (9%) 58.058.0

Other race*Other race* 28,528 (4%)28,528 (4%) 50.550.5

Sub-site

Proximal ColonProximal Colon 316,087 (44%)316,087 (44%) 22.322.3

Distal ColonDistal Colon 191,607 (27%)191,607 (27%) 13.613.6

RectumRectum 205,941 (29%)205,941 (29%) 14.614.6

Stage

EarlyEarly 274,461 (37%)274,461 (37%) 19.419.4

LateLate 422,704 (56%)422,704 (56%) 29.929.9

UnstagedUnstaged 53,080 (7%)53,080 (7%) 3.73.7

*Other races includes American Indian/Alaska Native, Asian or Pacific Islander, and persons of unknown race.

Invasive CRC by Age and RaceInvasive CRC by Age and RaceUnited States, 1998-2003United States, 1998-2003

Age < 50 Age ≥ 50

Number

(%)

Incidence Rate (per 100,000)

Number

(%)

Incidence Rate (per 100,000)

White White 48,315 48,315

(6.4%)(6.4%)

5.75.7 607,176 607,176

(81%)(81%)

174.7174.7

African African AmericanAmerican

8,3008,300

(1.1%)(1.1%)

7.57.5 57,933 57,933

(8%)(8%)

190.0190.0

Other Other racesraces

3,6263,626

(0.5%)(0.5%)

6.26.2 23,10723,107

(3%)(3%)

166.5166.5

Total N = 750,252 malignant tumors

*Other races includes American Indian/Alaska Native, Asian or Pacific Islander, and persons of unknown race.

Incidence by Specific Age & RaceIncidence by Specific Age & Race

AgeAge 45-49 years, 45-49 years, ≥50 years≥50 years

RaceRace African Americans, WhitesAfrican Americans, Whites

Sub-siteSub-site Right (Proximal) vs. Left (Distal + Rectum)

Stage at Stage at diagnosisdiagnosis

Early vs. Late

Colorectal Cancer Incidence Rates by Age and Race USA 1998-2003

Rates are age-adjusted except when age-specified

RR=1.39*RD=10.5

RR=1.09*RD=15.3

RD is per 100,000* Indicates p<0.05

0

50

100

150

200

250

age 45-49 age ≥ 50

Age at Diagnosis (years)

Rat

e p

er 1

00,0

00

White

AfricanAmerican

Colorectal Cancer Incidence Rate Colorectal Cancer Incidence Rate by Sub-site, Age, and Race, USAby Sub-site, Age, and Race, USA

Source Data: NPCR/SEER 1998-2003

0

20

40

60

80

100

Ag

e-A

dju

ste

d R

ate

pe

r 1

00

,00

0

White

AfricanAmerican

RR=1.16*RD=12.2

RR=0.99*RD=-1.3

Right Colon Left Colon Right Colon Left Colon

Age 45-49 Age ≥ 50

RR=1.86*RD=6.4

RR=1.18*RD=3.2

RD is per 100,000* Indicates p<0.05

Colorectal Cancer Incidence Rate Colorectal Cancer Incidence Rate by Stage, Age, and Race, USAby Stage, Age, and Race, USA

Source Data: NPCR/SEER 1998-2003

0

20

40

60

80

100

120

Ag

e-A

dju

ste

d R

ate

pe

r 1

00

,00

0

White

AfricanAmerican

RR=1.22*RD=1.9

RR=1.46*RD=7.6

RR=0.95*RD=-3.4

RR=1.14*RD=14.0

Early Late Early Late

Age 45-49 Age ≥ 50

RD is per 100,000* Indicates p<0.05

SummarySummary

Higher incidence rates among African Americans Higher incidence rates among African Americans 10 to15 more cancers/100,000 population 10 to15 more cancers/100,000 population

By sub-site, overall greater burden in left colon vs. By sub-site, overall greater burden in left colon vs. right colonright colon 6 to12 more cancers/100,000 in the right (proximal) 6 to12 more cancers/100,000 in the right (proximal)

colon among African Americans ages 45-49 and colon among African Americans ages 45-49 and ≥ 50≥ 50 3 more cancers/100,000 in the left colon among African 3 more cancers/100,000 in the left colon among African

Americans age 45-49 Americans age 45-49

By stage, overall greater burden of late vs. By stage, overall greater burden of late vs. early stage early stage 8 to 14 more cancers/100,000 at late stage among 8 to 14 more cancers/100,000 at late stage among

African Americans ages 45-49 and African Americans ages 45-49 and ≥ 50≥ 50

Strengths and LimitationsStrengths and Limitations

StrengthsStrengths NPCR/SEER combined data are most recentNPCR/SEER combined data are most recent Data provides national representation Data provides national representation

LimitationsLimitations The number of cases of disease in the U.S. is The number of cases of disease in the U.S. is

actually higher actually higher Hispanics are inclusive in the race categoryHispanics are inclusive in the race category This is a cancer registry not polyp registryThis is a cancer registry not polyp registry

DiscussionDiscussionIssues to be considered:Issues to be considered: BurdenBurden

(Incidence, counts, RR and AR)(Incidence, counts, RR and AR) CostsCosts Endoscopic capacity Endoscopic capacity Risks associated with screeningRisks associated with screening Patient preferencesPatient preferences Resource allocationResource allocation Impact of early screening on population mortality Impact of early screening on population mortality There may be other considerations… There may be other considerations…

Each of these considerations will be viewed Each of these considerations will be viewed differently from the public health, clinical, and differently from the public health, clinical, and policy perspective.policy perspective.

Contact InformationContact Information

For more information please contact:For more information please contact:

Sun Hee Rim MPHSun Hee Rim MPHASPH/CDC FellowASPH/CDC FellowDivision of Cancer Prevention and ControlDivision of Cancer Prevention and ControlCenters for Disease Control and PreventionCenters for Disease Control and Prevention4770 Buford Highway NE, MS K-554770 Buford Highway NE, MS K-55Atlanta, GA 30341-3724Atlanta, GA 30341-3724(770) 488-3252 office(770) 488-3252 officeSRim@cdc.govSRim@cdc.gov

http://www.cdc.gov/cancer/http://www.cdc.gov/cancer/

AcknowledgementsAcknowledgementsLaura Seeff MD, Faruque Ahmed MD PhD, Jessica King MPH, Steven Laura Seeff MD, Faruque Ahmed MD PhD, Jessica King MPH, Steven Coughlin PhD Coughlin PhD