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Cancer by Neighborhood

Cancer by Neighborhood. Thomas Mack, M.D., M.P.H. Keck School of Medicine University of Southern California. Neighborhood Cancer Problems. Worry about a local “cancer cluster” AND/OR Worry about a local hazard that could cause cancer cases. The necessary questions.

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Cancer by Neighborhood

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  1. Cancer by Neighborhood Thomas Mack, M.D., M.P.H. Keck School of Medicine University of Southern California

  2. Neighborhood Cancer Problems • Worry about a local “cancer cluster” AND/OR • Worry about a local hazard that could cause cancer cases

  3. The necessary questions • How frequently does cancer normally occur? • What factors predict local cancer frequency? • How do we identify causes of cancer? • What are the known causes of cancer? • What causes are in the residential environment? • What environmental clusters have occurred? • What are the problems in assessing clusters? • What specifics relate to this local concern?

  4. How frequently does cancer normally occur? From place to place From cancer site to cancer site By sex, race, and especially age

  5. Estimated Lifetime US Cancer Risk* Men 45% Women36% • Of Total • 12% Breast • 5% Lung & bronchus • 3% Colon & rectum • 3% Uterine corpus • 2% Ovary • 1% Melanoma of skin • 1% Thyroid • 1% Kidney & renal pelvis • 1% Non-Hodg. lymphoma • 1% Pancreas • 1% Uterine cervix • 1% Leukemia • 4% Any Other Site Of Total Prostate 15% Lung & bronchus 6% Colon & rectum 4% Urinary bladder 3% Melanoma of skin 2% Non-Hodg lymphoma 2% Kidney & renal pelvis 1% Leukemia 1% Oral cavity 1% Pancreas 1% Stomach 1% Any Other Site 8% *Excludes basal and squamous cell skin cancers and in situ carcinomas except urinary bladder. Source: American Cancer Society, 2009.

  6. 2009 Estimated US Cancer Deaths* Men292,540 Women269,800 • Of Total • 26% Lung & bronchus • 15% Breast • 9% Colon & rectum • 6% Pancreas • 5% Ovary • 4% Non-Hodg. lymphoma • 3% Leukemia • 2% Uterine cervix • 2% Liver & bile duct • 2% Brain/ONS • 1% Uterine corpus • 25% All other sites Of Total Lung & bronchus 30% Prostate 9% Colon & rectum 9% Pancreas 6% Leukemia 4% Liver & bile duct 4% Esophagus 4% Urinary bladder 3% Non-Hodg. lymphoma 3% Kidney & renal pelvis 3% All other sites 25% ONS=Other nervous system. Source: American Cancer Society, 2009.

  7. Cancer at All SitesLos Angeles v. Other Places USA

  8. Cancer at All SitesLos Angeles v. Other Places USA

  9. What factors predict local cancer frequency? Los Angeles County

  10. Risk to Neighborhoods is more variable • Residents tend to be similar • Smaller frequencies make less stable estimates

  11. US

  12. Colon Carcinoma in LA (common)

  13. Cervix Carcinoma in LA (rare)

  14. Carcinoma of the Sigmoid Colon, Males

  15. Kaposi Sarcoma, Males

  16. Geographic Variation in Cancer Occurrence • Chance (especially among small places) • Demographic gradients • Age, Race and Gender • Ethnicity and culture • Education and income • Lifestyle and Occupation • Medical care • Rarely from geographic environment

  17. Age, Race and Gender

  18. Lung Cancer

  19. Lung Cancer

  20. Breast Carcinoma

  21. Prostate Cancer

  22. Ethnicity and Culture Specific variation in Los Angeles Race/Ethnicity Gall Bladder Cancer in Latinas Birthplace Liver Cancer in East Asian-Born

  23. Education and Income • Variations linked to both extremes • High income, much education • Unrestricted consumption • Abundant medical care, medications • Late reproduction • Low income, little education • Ignorance of risk (tobacco, infections, etc) • Paucity of medical care, advice • Early Reproduction

  24. Breast Cancer: High educated tracts, strictly because of social class Cervical Cancer: Low income tracts, strictly because of social class Social Class and Cancer

  25. Lifestyle and Occupation Workplace Exposures Habits and Recreational Exposures

  26. MESOTHELIOMA

  27. KAPOSI SARCOMA

  28. Medical Care Selective access to therapy ad libitum Endometrial Cancer Selective access to diagnostic facilities, testing Papillary thyroid cancer, prostate cancer Selective motivation for screening from media Breast cancer in a celebrity

  29. WITH CHARACTERISTIC PATTERN Oropharynx CA Sq Esophagus Adenoca Stomach Upper Colon Hepatoma Gallbladder Larynx Squamous Lung Small Cell Lung Large Cell Lung Adenoca Lung Mesothelioma Kaposi Sarcoma NS Hodgkin’s Dis Melanoma Breast Cancer Cervix Cancer Endometrial CA Prostate CA AnogenitalSq CA Squamous Bladder Papill. Thyroid CA Large B-cell NHL Immature C. NHL Sm.B/Mixed NHL Mult. Myeloma

  30. NO CHARACTERISTIC PATTERN Mixed Salivary Stomach Cardia Small Bowel Sigmoid Colon Rectum Cholangiocarcinoma Biliary Tract Pancreas Nose/Sinuses Soft Tissue Sarcoma Angiosarcoma Osteosarcoma Ovarian CA Germ Cell Carcinoma Acute Myelocytic Leukemia Bladder Kidney Wilms Tumor Brain Retinoblastoma Neuroblastoma Follicular Thyroid Multiple Endocrine Neoplasm Mixed Cell Hodgkin’s Lymphoma Follicular Non-Hodgkin lymphoma T-cell Non-Hodgkin Lymphoma Acute Lymphoblastic Leukemia Chronic Lymphocytic Leukemia Chronic Myelocytic Leukemia Mixed Cell Genital Neoplasm

  31. How do we identify causes of cancer? • Cause: • Something that if eliminated, prevents cancer • Genes orand Environment • Environment or Environment • Every cause that is not inherited • Workplace or Residence • Factors may predict cancer but not cause it

  32. Genetic Factors (Causal Genes) • Play a role in all forms of cancer • Usually create susceptibility to environment • Usually only a small proportion from any gene • The most important cause of a few rare cancers

  33. Finding Causes (Environmental Carcinogens) • Sources of Information • Clinical anecdotes • Lab In vitro mechanistic biology • Animal testing • Epidemiological Patterns

  34. All tools are imperfect • Clinical and lab observations not definitive • Rarely well controlled or statistically sound • Human repair mechanisms are unaccounted for

  35. All tools are imperfect • Animals are not like people • Don’t live long enough for carcinogens to act • Have different anatomy and physiology • No clear basis for extrapolating results

  36. All tools are imperfect • Can’t do experiments • “Natural” epidemiologic observations are hard • Opportunities with enough exposure rare • Multiple exposures usual • Dosage approximate • Like democracy, the worst except for the others • Must exclude chance, bias, other explanations

  37. Formal Criteria designating carcinogens are used to guide regulation • THE MODEL CRITERIA: • International Agency for Cancer Research • Definite, Probable, Possible, Unclassifiable • EPA, FDA, NTP • CANADA, OTHERCOUNTRIES,STATES • CALIFORNIA EPA: PROPOSITION 65

  38. Our knowledge is incomplete • Every kind of cancer has unique causes • A few exposures cause multiple kinds • Smoking • Ionizing radiation • Chemotherapeutic chemicals • Every case has multiple causes • Our ignorance varies by type • An unexplained excess may give a lead

  39. DEFINITE ENVIRONMENTAL CARCINOGENS >20 INDUSTRIAL CHEMICALS; >15 PROCESSES >15 INORGANIC PRODUCTS, >15 METALS/ MINERALS >30 PHARMACOLOGIC PRODUCTS 10 FOOD/DRINKS/HABITS 10 INFECTIOUS AGENTS 5 FORMS OF RADIATION 3 INSECTICIDES/HERBICIDES

  40. Carcinogenic exposures in the workplaceHeavy doses • Airborne arsenic, asbestos, hexavalent chromium • Airborne asbestos • Other heavy metal dusts: e.g. nickel • Products of combustion: soot, diesel exhaust • Industrial dioxins, PCB’s PBB’s, vinyl chloride • Toxic gas and mists: strong acids, mustard gas • Refinery products like benzene and benzidene • Solvents: carbon tetrachloride, TCE, • Agricultural Pesticides: arsenic, chlordane, dieldrin

  41. CHRONIC LIFESTYLE CARCINOGENS • TOBACCO FOR SMOKING OR CHEWING • ALCOHOL • SOLAR RADIATION • DRUGS AND HORMONES • DIETARY PREFERENCES (WELL-DONE MEAT) • OBESITY/SEDENTARY LIFESTYLE • PHYSIOLOGIC OR THERAPEUTIC HORMONES

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