Evaluation of Childhood Cancer Incidence in Sandwich, MA: 1995 - Present

1. Evaluation ofChildhood Cancer Incidence in Sandwich, MA: 1995 - Present Massachusetts Department of Public Health Center for Environmental Health Community Assessment Program February 28, 2006

2. Protect the public health from a variety of environmental exposures Respond to environmental health concerns and provide communities with epidemiologic and toxicological health assessments Center for Environmental Health (CEH)

3. 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 Community Assessment Program (CAP)

4. 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 Reason for Investigation

5. 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 Steps in the Investigation

6. 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) Geographic Distribution

7. 12,158 children in the United States were diagnosed with cancer in 2002 267 children in Massachusetts were diagnosed with cancer in 2002 Childhood Cancer Statistics

8. 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

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

10. Statistical Methods • Standardized Incidence Ratio (SIR) • 95% Confidence Interval

11. Population-based surveillance system established in 1982 Massachusetts law requires reporting of all newly diagnosed primary cancers in MA residents Confidential database Massachusetts Cancer Registry (MCR)

12. 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 MCR (cont’d)

13. Cape Cod Childhood Cancer: 1995 – 2002 SIR and 95% CI not calculated when Observed is less than 5

14. 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 Review of Cape Cod Childhood Cancer

16. Childhood Cancer Incidence in Sandwich, MA: 1995-2002

17. Childhood Cancer Incidence in Sandwich Census Tracts: 1995-2002

18. Cancer Types Diagnosed1995-2002

19. Distribution of Childhood Cancer Diagnoses: 1995 - 2002

20. Cancer Types Diagnosed2003-2005

21. Distribution of Childhood Cancer Diagnoses: 2003 - 2005

22. 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?

23. 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?

24. 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 What Do We Know About Childhood Cancer?

25. 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

26. 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 Results1995-2002

27. 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 Summary of Results 2003 – 2005

28. 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 Geographic Distribution 1995 - 2005

29. 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% Environmental Review *Source: 1990 US Census Data

30. 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

31. Work with local health officials to obtain updated information on private well use To extent possible, review additional environmental factors of concern to community Recommendations for Follow-up(cont’d)

32. 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 Next Steps

33. 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 Contact Information