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

1. Disparities in Colorectal Cancer Incidence, USA 1998-2003:An Updated NPCR/SEER Data Analysis Sun Hee Rim MPH Laura Seeff MD Faruque Ahmed MD PhD Jessica King MPH Steven Coughlin PhD American Cancer Society Cancer Disparities Conference April 18-20, 2007 Division of Cancer Prevention and Control, Center for Disease Control and Prevention, Atlanta, Georgia

2. Disclaimer The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Center for Disease Control and Prevention.

3. Background on Colorectal Cancer • Second leading cause of cancer deaths in the USA • Burden of disease is high but unequal across subpopulations • Screening = prevention & early detection • 5-year relative survival rate for localized colorectal cancer is 90%

4. Colorectal Cancer in African Americans • Higher CRC incidence • Younger average age at diagnosis • Higher proportion present disease at age<50 years • More proximal disease • SEER data

5. Current Screening Guidelines • National Guidelines • U.S. Preventive Services Task Force • American Cancer Society • U.S. Multi-society Task Force on CRC Screening • Recommended for all average risk persons regardless of race/ethnicity and sex

6. Tailored Screening Guidelines? • Should screening guidelines take into account burden by demographic subgroups? • Suggested modification of CRC guidelines for African Americans by American College of Gastroenterology • Beginning age 45 • Colonoscopy rather than flexible sigmoidoscopy

7. Objective • To describe the most current burden of CRC • Updated, nationally representative NPCR/SEER cancer surveillance data • By subpopulations • Current analysis • African Americans compared to whites • Age 45-49 and ≥ 50 years • Incidence rates by sub-site and stage

8. CDC’s National Program of Cancer Registries (NPCR) and NCI’s Surveillance, Epidemiology, and End Result (SEER) Slide courtesy of Cancer Surveillance Branch, DCPC, CDC http://apps.nccd.cdc.gov/cancercontacts/npcr/contacts.asp

9. Methods • Incidence rates (IR) were age-adjusted by the Direct Method to the 2000 U.S. standard population • 95% CI and p-values were calculated • Rate Ratio (RR) was defined as the ratio of the age-adjusted incidence rates • Rate Ratio = (IRAfrican Americans)/(IRWhites) • Rate Difference (RD) measured the difference between the rates (per 100,000 population) • Rate Difference = (IRAfrican Americans)-(IRWhites)

10. Definition of Stage & Sub-site

11. Diagram of the Colon Splenic flexure Hepatic Flexure Left Colon (Distal Colon + Rectum) Right Colon (Proximal)

12. Burden of DiseaseInvasive CRC by Selected Features,United States, 1998-2003

13. Invasive CRC by Selected Features,United States, 1998-2003 *Other races includes American Indian/Alaska Native, Asian or Pacific Islander, and persons of unknown race.

14. Invasive CRC by Age and RaceUnited States, 1998-2003 Total N = 750,252 malignant tumors *Other races includes American Indian/Alaska Native, Asian or Pacific Islander, and persons of unknown race.

15. Incidence by Specific Age & Race

16. Colorectal Cancer Incidence Rates by Age and Race USA 1998-2003 RR=1.09* RD=15.3 RR=1.39* RD=10.5 RD is per 100,000 * Indicates p<0.05 Rates are age-adjusted except when age-specified

17. Colorectal Cancer Incidence Rate by Sub-site, Age, and Race, USA RR=1.16* RD=12.2 RR=0.99* RD=-1.3 RR=1.18* RD=3.2 RR=1.86* RD=6.4 RD is per 100,000 * Indicates p<0.05 Right Colon Left Colon Right Colon Left Colon Age 45-49 Age ≥ 50 Source Data: NPCR/SEER 1998-2003

18. Colorectal Cancer Incidence Rate by Stage, Age, and Race, USA RR=1.14* RD=14.0 RR=0.95* RD=-3.4 RR=1.46* RD=7.6 RD is per 100,000 * Indicates p<0.05 RR=1.22* RD=1.9 Early Late Early Late Age 45-49 Age ≥ 50 Source Data: NPCR/SEER 1998-2003

19. Summary • Higher incidence rates among African Americans • 10 to15 more cancers/100,000 population • By sub-site, overall greater burden in left colon vs. right colon • 6 to12 more cancers/100,000 in the right (proximal) colon among African Americans ages 45-49 and ≥ 50 • 3 more cancers/100,000 in the left colon among African Americans age 45-49 • By stage, overall greater burden of late vs. early stage • 8 to 14 more cancers/100,000 at late stage among African Americans ages 45-49 and ≥ 50

20. Strengths and Limitations • Strengths • NPCR/SEER combined data are most recent • Data provides national representation • Limitations • The number of cases of disease in the U.S. is actually higher • Hispanics are inclusive in the race category • This is a cancer registry not polyp registry

21. Discussion • Issues to be considered: • Burden (Incidence, counts, RR and AR) • Costs • Endoscopic capacity • Risks associated with screening • Patient preferences • Resource allocation • Impact of early screening on population mortality • There may be other considerations… • Each of these considerations will be viewed differently from the public health, clinical, and policy perspective.

22. Contact Information For more information please contact: Sun Hee Rim MPH ASPH/CDC Fellow Division of Cancer Prevention and Control Centers for Disease Control and Prevention 4770 Buford Highway NE, MS K-55 Atlanta, GA 30341-3724 (770) 488-3252 office SRim@cdc.gov http://www.cdc.gov/cancer/ Acknowledgements Laura Seeff MD, Faruque Ahmed MD PhD, Jessica King MPH, Steven Coughlin PhD