Disparities in Cancer Incidence Among Residents of Appalachia Ohio

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1 Disparities in Cancer Incidence Among Residents of Ohio Ohio Cancer Incidence Surveillance System The Ohio Department of Health Arthur G. James Cancer Hospital and Richard J. Solove Research Institute The Ohio State University NAACCR 2005 Annual Meeting June 7, 2005

2 n Region of the United States

3 Characteristics of 410 counties in 13 states, stretching from southern New York to northeast Mississippi Counties range from metropolitan (58%) to rural (42%), compared to 20% rural in the nation Employment has diversified over the past 15 years: Prior to 1990: Industry, agriculture, mining Today: Service industry, retail, government

4 Characteristics of, cont. has been characterized as a region of health disparities: Health disparities are differences in the incidence, prevalence, mortality and burden of disease among specific populations

5 Characteristics of, cont. Greater proportion of counties with high rates of unemployment Lower per-capita income (81.9% of U.S. average) 121 (30%) counties designated as economically distressed (Fiscal year 2004; n Regional Commission 2003) Lower percentage of persons (age 25+) with a high school diploma or college degree Limited access to care: greater distance to medical facilities and lack of transportation High prevalence of cancer-related health behaviors: High rates of obesity, smoking and physical inactivity Low rates of mammography and Pap tests

6 Ohio Ohio ADAMS ALLEN ATHEN AUGLAIZE BROWN BUTLER CHAMPAIGN CLARK CLINTON CRAWFORD CUYAHOGA DARKE ERIE FAIRFIELD FAYETTE FRANKLIN FULTON GALLIA GREENE HAMILTON HANCOCK HARDIN HENRY HIGHLAND HOCKING HURON JACKSON LAWRENCE LOGAN LORAIN LUCAS MADI- MARION MEDINA MEIGS MERCER MIAMI MONROE MORROW MUSK- NOBLE OTTAWA PAULDING PERRY PICKAWAY PIKE PREBLE PUTNAM RICH- ROSS SANDUSKY SCIOTO SENECA SHELBY SUMMIT TUSCA- UNION VAN WERT VINTON WARREN WASHINGTON WAYNE WILLIAMS WOOD WYANDOT CLER- MONT GOMERY MONT- JEFFER-- SON SON LAND RAWAS INGUM ASH- LAND ASHTABULA CARROLL COLUMBIANA GEAUGA LAKE MAHONING PORTAGE STARK TRUMBULL BELMONT COSHOCTON DELAWARE GUERNSEY HARRISON HOLMES KNOX LICKING DEFIANCE MORGAN ADAMS ATHENS BROWN GALLIA HIGHLAND HOCKING JACKSON LAWRENCE MEIGS MONROE MORGAN MUSK- NOBLE PERRY PIKE ROSS SCIOTO TUSCA- VINTON WASHINGTON CLER - MONT SON RAWAS INGUM CARROLL COLUMBIANA BELMONT COSHOCTON GUERNSEY HARRISON HOLMES JEFFER-

7 Ohio Demographics* 29 counties along the eastern and southern border 2000 Census of Population: 1,455,313 persons; 13% of Ohio s population 49.1% Male, 50.9% Female 96.1% White, 2.1% African American Land Use: 37.4% Agricultural, 1.2% Urban Unemployment Rate: 5.7% (versus 4.0% for Ohio) Registered Hospitals: 33 * Source: 2003 Ohio County Profiles, Ohio Department of Development, 2005.

8 Objectives Illustrate disparities in cancer incidence and mortality in versus non- Ohio, focusing on leading and screenable sites/types of cancer Explore factors that may contribute to these disparities, including: health behaviors, stage at diagnosis, income, education, insurance status and access to medical care

9 Sources of Data Incidence: Ohio Cancer Incidence Surveillance System (OCISS), (March 2005) Primary cancers diagnosed among Ohio residents Coded to the ICD-O-3; SEER site/type groupings Mortality: Vital Statistics Program, Ohio Department of Health, (March 2005) Ohio residents with an underlying cause of death of cancer Coded to the ICD-9 (1998) and ICD-10 ( ) Health Behaviors: Ohio Behavioral Risk Factor Surveillance System,

10 and Non- Ohio Age-adjusted Cancer Incidence Rates * by Site/Type, Cancer Site/Type Non- % Difference All Sites/Types % Breast (Female) % Cervix % Colon and Rectum % Lung and Bronchus % Melanoma of Skin % Oral Cavity/Pharynx % Prostate % *Average annual rates per 100,000, age adjusted to the U.S standard population. Note: A number of additional sites/types had a high percent difference in versus non- Ohio: brain and other CNS (7.7%); corpus uterus (6.4%); Hodgkin s lymphoma (6.9%); leukemias (8.4%); non-hodgkin s lymphoma (7.4%); and thyroid (13.6%).

11 and Non- Ohio Age-adjusted Cancer Mortality Rates * by Site/Type, Cancer Site/Type Non- % Difference All Sites/Types % Breast (Female) % Cervix % Colon and Rectum % Lung and Bronchus % Melanoma of Skin % Oral Cavity/Pharynx % Prostate % *Average annual rates per 100,000, age adjusted to the U.S standard population. Note: A number of additional sites/types had a high percent difference in versus non- Ohio: brain and other CNS (12.5%); Hodgkin s lymphoma (40.0%); larynx (7.1%); non- Hodgkin s lymphoma (7.9%); and testis (150.0%).

12 and Non- Ohio Cancer-related Screening Behaviors, Ever Had a Mammogram (40+) 82.8% 89.8% Mammogram Past Two Years (40+) Pap Smear Past Three Years (18+, intact cervix) 69.3% 77.6% 79.0% 86.9% Non- PSA Past Year (50+) DRE Past Year (50+) 58.6% 56.3% 54.6% 51.3% Sigmoidoscopy/Colonoscopy Past Five Years (50+) 31.9% 38.6% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Percent (%) The prevalence of screening for breast, cervical and colorectal cancer is lower in versus non- Ohio.

13 and Non- Ohio Cancer-related Health Behaviors (Age 18+), Percent (%) 90% 80% 70% 60% 50% 40% 30% 20% 31.5% 26.1% 23.4% 22.3% 29.4% 28.6% 78.9% 77.1% Non- 10% 0% Current Smoker Obese No Leisure Time Physical Activity <Five Servings of Fruits and Vegetables The prevalence of current cigarette smoking, obesity, no leisure time physical activity and inadequate fruit and vegetable consumption is higher in versus non- Ohio.

14 and Non- Ohio Percent Late Stage at Diagnosis by Cancer Site/Type, Cancer Site/Type Breast (Female) Cervix Colon and Rectum Lung and Bronchus Melanoma of Skin Oral Cavity and Pharynx Prostate 8.2% 6.8% 9.1% 10.4% 26.1% 26.7% 32.6% 36.0% 49.6% 50.9% 48.3% 49.1% 58.6% 59.7% 0% 10% 20% 30% 40% 50% 60% 70% Percent Late Stage (%) Melanoma of Skin is the only cancer site/type with a greater percent late stage at diagnosis in versus non- Ohio. Non-

15 Cervical Cancer in Ohio Age-adjusted Incidence Rates by Quartile of Median Household Income*, Average Annual Rate per 100, $0-$30,133 $30,134-$39,202 $39,203-$49,451 $49,452 + Quartile of Income Cervical cancer incidence decreases with increasing quartile of income. Cervical cancer incidence is 42.0 % greater in vs. non- Ohio. * Census 2000 Summary File 3 (SF 3) Sample Data. Quartiles of median household income were determined for the state of Ohio and then assigned to each census tract. Persons with a residence of diagnosis within a particular census tract were assigned to the quartile of income for that census tract.

16 Colon and Rectum Cancer in Ohio Age-adjusted Incidence Rates by Quartile of Median Household Income*, Average Annual Rate per 100, $0-$30,133 $30,134-$39,202 $39,203-$49,451 $49,452 + Quartile of Income Colorectal cancer incidence decreases with increasing quartile of income. Colorectal cancer incidence is 14.2% greater in vs. non- Ohio. * Census 2000 Summary File 3 (SF 3) Sample Data. Quartiles of median household income were determined for the state of Ohio and then assigned to each census tract. Persons with a residence of diagnosis within a particular census tract were assigned to the quartile of income for that census tract.

17 Prostate Cancer in Ohio Age-adjusted Incidence Rates by Quartile of Median Household Income*, Average Annual Rate per 100, $0-$30,133 $30,134-$39,202 $39,203-$49,451 $49,452 + Quartile of Income Prostate cancer incidence is highest in the highest quartile of income. Prostate cancer incidence is 8.3% less in vs. non- Ohio. * Census 2000 Summary File 3 (SF 3) Sample Data. Quartiles of median household income were determined for the state of Ohio and then assigned to each census tract. Persons with a residence of diagnosis within a particular census tract were assigned to the quartile of income for that census tract.

18 and Non- Ohio Educational Attainment (age 25+)*, % 22% Non- 22% 16% 22% 44% 26% 36% < High School High School Some College College Degree Residents of compared to non- Ohio are more likely to have an educational attainment less than high school and less likely to have a college degree. * Census 2000 Summary File 3 (SF 3) Sample Data.

19 and Non- Ohio Primary Payer at Diagnosis, Not Insured 3.4% 3.4% Primary Payer at Diagnosis Managed Care, HMO, PPO Medicaid Medicare Other/Unspecified Unknown/Not Reported 3.7% 2.5% 8.9% 17.3% 17.1% 17.0% 16.2% 27.3% 39.6% 43.6% Non- 0% 10% 20% 30% 40% 50% Percent (%) Persons with cancer in versus non- Ohio are less likely to have managed care, HMO, PPO plans and Medicare but are equally likely to have no health insurance.

20 and Non- Ohio Type of Reporting Source at Diagnosis, % 90% 80% 90.8% 90.2% Non- 70% Percent (%) 60% 50% 40% 30% 20% 10% 0% Hospital or Clinic 5.5% 5.8% Physician's Office/ Private Practitioner 2.9% 2.7% 0.9% 1.4% Death Certificate Only/ Autopsy Other Type of Reporting Source There is little difference in type of reporting source between and non- Ohio.

21 Hospital Locations in Ohio Insert Map Hospital Source: ESRI GIS and mapping software, Total Hospitals 33 n Hospitals Only 33 hospitals are located in the 29-county Ohio region. Six counties in Ohio do not have a hospital facility.

22 Conclusions Disparities in cancer incidence are found in Ohio for all cancer sites/types combined and cancers of the cervix; colon and rectum; lung and bronchus; and oral cavity and pharynx. Disparities in cancer mortality are found in Ohio for all cancer sites/types combined and cancers of the cervix; colon and rectum; lung and bronchus; and melanoma of the skin. The high rates of cervical and colorectal cancer mortality in Ohio may be associated with the lower prevalence of screening for these cancers.

23 Conclusions, cont. The high rates of lung and bronchus cancer incidence and mortality in Ohio may be due to the high prevalence of cigarette smoking in the region. Ohio has a lower per capita income compared to non-, and a direct relationship is found between low income and high rates of cervical and colorectal cancer in the region. Persons diagnosed with cancer in and non- Ohio are equally likely to be uninsured and reported from hospital facilities. Differences in access to appropriate care, however, may be associated with cancer disparities.

24 Contact Information Holly L. Engelhardt, MS: James L. Fisher, PhD: Julie A. Stephens, MS: Acknowledgements: Bette R. Smith, BHIT, RHIT, CTR Georgette G. Haydu, MS Robert W. Indian, MS Electra D. Paskett, PhD