Evaluation ofChildhood Cancer Incidence

in Sandwich, MA: 1995 - Present

Massachusetts Department of Public HealthCenter for Environmental HealthCommunity Assessment Program

February 28, 2006

Center for Environmental Health (CEH)

Protect the public health from a variety of environmental exposures

Respond to environmental health concerns and provide communities with epidemiologic and toxicological health assessments

Community Assessment Program (CAP)

Evaluate frequency and patterns of disease in the population

Respond to concerns about suspected disease patterns or “clusters”

Investigate possible associations between environmental exposure and disease

Reason for Investigation

Concerns about increased cancer incidence among children

Requested by: Concerned resident from Sandwich A specific environmental concern was not

reported to CAP

Reports of more recent diagnoses of cancer among children

Steps in the Investigation

Cancer evaluation Calculate cancer incidence rate among children

diagnosed during time period 1995-2002 Review cancer types diagnosed (1995 – present) Evaluate geographic and temporal patterns of

childhood cancer (1995 – present)

Evaluate potential environmental concerns Public drinking water Location of groundwater plumes from MMR

Geographic Distribution

Map locations of residence reported at time of diagnosis

Evaluate spatial patterns of childhood cancer in neighborhoods within each community

Evaluate patterns of childhood cancer in relation to environmental sources (e.g. MMR plumes)

Childhood Cancer Statistics

12,158 children in the United States were diagnosed with cancer in 2002

267 children in Massachusetts were diagnosed with cancer in 2002

Cancer in Children Versus Cancer in Adults

CHILDREN Different cancers may

be more similar with respect to risk factors

Little information is known about risk factors

ADULTS Different cancers are

different diseases

Much is known about risk factors for a number of cancer types

Cancer in Children Versus Cancer in Adults (cont’d)

Common Childhood Cancers

Leukemia

CNS tumors

Bone tumors

Common Adult Cancers

Lung

Colon

Breast

Prostate

Statistical Methods

Standardized Incidence Ratio (SIR)

SIR = Observed # of cases

X 100Expected # of cases

95% Confidence Interval

Massachusetts Cancer Registry (MCR)

Population-based surveillance system established in 1982

Massachusetts law requires reporting of all newly diagnosed primary cancers in MA residents

Confidential database

MCR (cont’d)

Statewide and city/town data are complete through 2002 Data for 2003 being prepared for release soon

Diagnoses reported to the MCR after 2002 are available for review

Contacted treatment facilities and the Rhode Island cancer registry

Cape Cod Childhood Cancer: 1995 – 2002

Town Observed Expected SIR 95% CI

Barnstable 14 14.4 97 53-163

Bourne 3 6.2 NC NC

Brewster 4 2.9 NC NC

Chatham 1 1.3 NC NC

Dennis 0 3.8 NC NC

Eastham 0 1.3 NC NC

Falmouth 9 9.3 96 44-183

Harwich 0 3.1 NC NC

Mashpee 7 4.0 175 70-361

Orleans 1 1.2 NC NC

Provincetown 0 0.5 NC NC

Sandwich 10 7.5 133 64-245

Truro 1 0.5 NC NC

Wellfleet 2 0.7 NC NC

Yarmouth 6 5.9 101 37-220SIR and 95% CI not calculated when Observed is less than 5

Review of Cape Cod Childhood Cancer

From 1995-2002, the observed number of diagnoses was near or below the number of expected cases for the majority of towns on Cape Cod

Preliminary review of more recent MCR data did not suggest patterns similar to those in SE Sandwich

Childhood Cancer Incidence in Sandwich, MA: 1995-2002

Observed Expected SIR 95% CI

Males 3 4.0 NC NC

Females 7 3.5 200 80-412

Total 10 7.5 133 64-245

Childhood Cancer Incidence in Sandwich Census Tracts: 1995-2002

Census tracts

Total Males FemalesOBS EXP SIR 95% CI OBS EXP SIR 95% CI OBS EXP SIR 95% CI

0133 1 0.9 NC NC 0 0.4 NC NC 1 0.4 NC NC

0134 2 1.3 NC NC 1 0.7 NC NC 1 0.6 NC NC

0135 5 2.6 192 62-449 1 1.4 NC NC 4 1.2 NC NC

0136 2 2.7 NC NC 1 1.4 NC NC 1 1.2 NC NC

Town 10 7.5 133 64-245 3 4.0 NC NC 7 3.5 200 80-412

Cancer Types Diagnosed1995-2002

Leukemia 3 children

CNS Tumor 3 children

Soft Tissue Sarcoma 2 children

Lymphoma (Hodgkin’s Disease)

1 child

Bone 1 child

Distribution of Childhood Cancer Diagnoses: 1995 - 2002

0

1

2

3

1995 1996 1997 1998 1999 2000 2001 2002

Cancer Types Diagnosed2003-2005

Leukemia 3 children

CNS Tumor 2 children

Bone 2 children

Distribution of Childhood Cancer Diagnoses: 2003 - 2005

0

1

2

3

4

2003 2004 2005

What Do We Know About Childhood Cancer?

Leukemia Most common type among children Incidence highest in ages 2-3 Pre-existing medical conditions (e.g., Down’s syndrome) Treatment with ionizing radiation Exposure to drinking water contaminated with solvents and

metals during pregnancy

CNS Tumors 2nd most common type Ages 15 years and younger Pre-existing medical conditions (e.g., Neurofibromatosis) Family history Treatment with ionizing radiation

What Do We Know About Childhood Cancer?

Hodgkin’s Disease (HD) Ages 15-19 Family history of HD Infection with Epstein Barr virus History of infectious mononucleosis

Bone (Ewing’s) Peak in incidence between ages 10 to 20 White children Other than race, no environmental factor or other

characteristic has yet been shown to be a strong risk factor

What Do We Know About Childhood Cancer?

Soft Tissue Sarcoma Rhabdomyosarcoma is the most common soft tissue

sarcoma in children Age less than 1 and children ages 15-19 Pre-existing medical conditions (e.g., Li-Fraumeni

syndrome, Beckwith-Wiedemann syndrome and Neurofibromatosis)

Treatment with ionizing radiation Exposure to pesticides

Summary of Results1995-2002

Town-wide cancer incidence occurred more often than expected Incidence among males slightly less than expected Females were diagnosed more often than expected

The number of diagnoses per year varied between 0 and 2

Age and cancer types diagnosed were consistent with literature

Summary of Results1995-2002

For 3 of 4 Sandwich CTs observed was close to the expected

From 1996-1999, 4 females residing in CT 0135 were diagnosed with cancer (versus 1.2 expected) 2 were diagnosed with leukemia 1 diagnosis of bone cancer 1 diagnosis of a soft tissue sarcoma

Summary of Results 2003 – 2005

From 2003-2005, 7 children were diagnosed with cancer 3 were diagnosed with leukemia 2 diagnoses of a CNS tumor 2 diagnoses of bone cancer

Age and cancer types diagnosed were consistent with literature

Geographic Distribution 1995 - 2005

Two areas noted in CT 0135 3 of the 6 children with leukemia lived in southeast

Sandwich at the time of diagnosis 2 children diagnosed with bone cancer lived in fairly

close proximity to one another in southern Sandwich

Environmental Review

Distribution did not appear to correspond to areas potentially affected by MMR plumes

Since 1993, no violations in Sandwich municipal drinking water (other than total coliform)

% of housing units on public water (estimate)* CT 0133 100% CT 0136 90% CT 0134 55% CT 0135 36%

*Source: 1990 US Census Data

Recommendations for Follow-up

Conduct interviews with biological mother of children diagnosed with cancer in Sandwich from 1995-present Pregnancy history Family medical history More complete residential history Parental occupational history

Conduct interviews with mothers of children diagnosed with cancer from 1995-present in Mashpee and Barnstable Request MCR to contact treatment facilities

Recommendations for Follow-up(cont’d)

Work with local health officials to obtain updated information on private well use

To extent possible, review additional environmental factors of concern to community

Next Steps

Approval of 24A application (early March meeting)

Mailing to parents with children diagnosed with cancer in Sandwich, Barnstable, and Mashpee during 1995-present

Obtain written consent from parents

Schedule and conduct interviews; collect medical records; obtain available environmental data

Data analysis

Prepare summary report of findings

Schedule public release

Contact Information

The full report is available at: http://www.mass.gov/dph/ceh.

CAP staff can be reached at: Phone: (617) 624-5757

Fax: (617) 624-5777