Cancer Deaths and the Environment in North Carolina

Transcription

1 Cancer Deaths and the Environment in North Carolina H. Kim Lyerly, M.D. Julia Kravchenko, M.D., Ph.D. Sung Han Rhew, Ph.D. Duke University

2 Introduction Environmental risk of cancer recognized by President s Cancer Panel in North Carolina residents exposed to a variety of possible environmental hazards

3 Geospatial mapping of environmental data and health data

4 Geographic patterns of potential environmental risk factors for cancer in North Carolina Appalachian area: radon, alpha-particles, high smoking prevalence. Geological/natural sources: arsenic in ground water.

5 Geographic distribution of environmental hazards Union county (as does a large part of the Charlotte region) sits directly on top of a slate belt, which naturally produces arsenic in the groundwater

6 Geographic patterns of potential environmental risk factors for cancer in North Carolina Hog commercial animal feeding operations (CAFOs): airborne particulate matters (PMs), insecticide, antibiotics, hormones, disinfectants, and other veterinary drugs. Coal ash ponds: PMs, mercury, arsenic, lead, chromium, vanadium, radioisotopes, and others.

7 CAFOs emit chemical pollutants contributing to cancer and other health effects (US EPA, 2014) Pollutant Risk factors and reference concentrations for chronic health effects Unit risk estimates for cancer Reference concentrations for non-cancer Affected organ or Weight of health risks, (ug/m 3 ) health effects, (mg/m 3 ) effect evidence Acetaldehyde 2.2x Respiratory B2 Benzene 7.8x Immune A Chloroform Liver B2 Dimethyl disulfide Reproductive n-hexane 0.7 Neurological Hydrogen sulfide Respiratory Methyl isobutyl ketone 3 Developmental Phenol 0.2 Liver D Styrene 1 Neurological 1,2,4-Trichlorobenzene 0.2 Liver D 1,1,1-Trichloroethane 5 Neurological D o-xylene 0.1 Neurological Notes: AEGL = Acute Exposure Guideline Level, ERPG = Emergency Response Planning Guideline, MRL = Maximum Residue Limit, IDLH = Immediately Dangerous to Life and Health, URE = unit risk estimates for cancer health risks, RFC = reference concentrations for non-cancer health effects

8 Adapted from Krauchenka et al, unpublished

9 Geographic distribution of environmental hazards

10 Methods: Data sources for health impact- cancer deaths, hospitalizations, and emergency visits Data sources used for analysis: Data for cancer mortality was from the NC State Center for Health Statistics, Vital Statistics Death, University of North Carolina (UNC) Dataverse; Data for hospital admissions and ED visits from the Healthcare Cost and Utilization Project (HCUP): the NC State Inpatient Database (HCUP SID data) and the NC State Emergency Department Database (HCUP SEDD data).

11 Fo ru m Methods: Geographic patterns of mortality, hospital admissions, and ED visits En vi ro nm en ta lh ea l th Sc ho l ar s Fa ll We assessed non-homogeneous patterns of cancers in North Carolina based on geographic distribution of mortality rates, hospitalizations rates, and emergency department (ED) visits in populations residing in the 822 communities of zip codes representing North Carolina

12 Methods: Known health outcome co-factors associated with commercial animal feeding operations (CAFOs), adjusted for in data analysis Characteristics Study group: 220 zip codes with hog CAFOs Control group: 602 zip codes without hog CAFOs Median household income $38,970** $46,504 Bachelor or higher degree education 16.42%** 24.07% Availability of primary care providers (per 100,000 population) 1 54** 76 Percent of uninsured individuals % 18.43% Smokers prevalence among those over 24+ years old % 23.47% Note: * <p<0.05; ** - p< Sources: U.S. Census Bureau, Censuses of Population, the American Community Survey (Education); Center for Disease Control (CDC), Behavioral Risk Factor Surveillance System (BRFSS)-smoking prevalence ; Health Resources & Services Administration (HRSA), Area Health Resources Files (AHRF)- primary care provider 2008,

13 Several nonhomogeneous geographic patterns of cancer in North Carolina were found. Odds ratios for cancer mortality, hospital admissions, and ED visits for several cancers are provided. Results

14 Although cancer mortality is higher in Appalachian residents, it is not higher that the rest of NC Source: Blackley et al, Journal of Community Health, 37(4), Residents of Appalachian area are known to have a higher cancer mortality rate. However, among 13 US states that form Appalachian area, NC residents do not have higher cancer-specific mortality than residents of non-appalachian NC areas.

15 Deaths from lung cancer in NC Ranked # 14 in the US for highest mortality in age group and #16 in age group 65+. Lung cancer age-adjusted mortality in NC vs. US, total for all ages, (CDC WONDER). US NC Lung cancer age-adjusted mortality, males aged 25-64, for Whites, African-Americans, and American Indians, (CDC WONDER) US NC US White AAs Am Ind Lung cancer age-adjusted mortality, males aged 65+, for Whites, African-Americans, and American Indians, (CDC WONDER) US NC US White AAs Am Ind NC NC US US NC NC

16 Deaths from lung cancer are increased in residents of communities with hog CAFOs or coal ash ponds Disease Age group NC total Hog CAFOs Coal Ash Ponds Control Lung cancer total * 57.09* Age * 15.02* Age * Note: * p<0.05 difference from control group. In addition to deaths, there are more lung cancer related ED visits: Residents of zip codes with hog CAFOs: ED visits, OR=1.237, p< Residents of zip codes with coal ash ponds: ED visits, OR=1.423, p< ED visits at age 20-44, OR=2.342, p<0.05

17 Deaths from respiratory cancer in NC are higher than in other hog farming states- Minnesota (MN) and Iowa (IA) Respiratory cancer rates in NC, IA, and MN areas with >200 hogs/km2 as compared to control areas without hog CAFOs (no such areas in IA): age-adjusted rates, , per 100,000 population, CDC WONDER. Disease >200 hogs/km2 Control Respiratory cancer (C30-C39), all races IA MN NC MN NC 43.7 ( ) White only 43.8 ( ) 38.4 ( ) 38.5 ( ) 60.3 ( ) 62.4 ( ) 46.5 ( ) 54.3* ( ) - - We performed an additional analysis for NC Residents of zip codes with hog CAFOs using an upper quartile of number of hogs per square km as threshold (215 hogs/km 2 ). In this area with very high concentration of hogs: Lung cancer hospital admissions, OR=1.047, p=0.0029, Lung cancer ED visits, OR=1.076, p<

18 Deaths from cancer of uterus/endometrium Smaller area of higher mortality on zip code map is associated with geographic locations of hog CAFOs in NC. White American women are at higher risk for endometrial cancer than black American women, with a 2.88% and 1.69% lifetime risk respectively. The highest rates in CAFOs are among African- American females. Increase in deaths from cancer of uterus in residents of zip codes with hog CAFOs: mortality, OR=1.166, p<0.05. Mortality at age 65+, OR=1.303, p< A greater increase in deaths from cancer of uterus in residents of zip codes with even more hogs >215 hogs/km 2 : mortality, OR=1.653, p< Hospital admissions, OR=1.146, p=

19 What can cause uterine cancer? Estrogenic compounds in NC Estrogenic compounds are discharged into the water. Many of these sources are related to human and animal waste: waste water treatment plants, agricultural areas where human sewage is applied to the land, and farms with confined animal feeding operations. (Sackett et al, 2015).

20 Analysis for the Distance from the Source of potential Contamination (DiSC) This analysis was developed because: There is decreasing exposure with increasing distance from the CAFO There are cluster of communities in rural NC areas (where hog CAFOs are located) which are unevenly distributed Suppose that released products from a CAFO can be represented as a bell-shaped distribution (see picture), with the maximum concentration of pollutants directly over the CAFO. Based on published reports that contaminants from the hog farm can be detected up to miles from the farm, we performed four radius-specific analyses: within 2 km (1.24 miles), within 5 km (3.11 miles), within 10km (6.21 miles), and within 20 km (12.43 miles) from each hog CAFO as a center of potential exposure.

21 Analysis for the Distance from the Source of potential Contamination (DiSC) Hog farm #3 Hog farm #2 Hog farm #1 An example: NC county (on example of Residents of zip codes in Duplin county) with zip codes boundaries and hog farms locations. We modeled exposures from all hog CAFOs in the area on the center of each studied zip code (the center means geographic location of the spot with the highest density of population living in this zip code): The circles represent potential exposures from each hog farm.

22 There is a higher rate of death from uterine cancer, the closer you live to a hog CAFO logistic regression, multivariate analysis (adjusted by income, education, health insurance, smoking, and availability of primary care providers), pooled for Disease Cancer of uterus Health outcome Mortality, all ages Mortality, ages 65+ Odd ratio (OR) 2km 5km 10 km 20 km 1.46, 1.15, 1.075, 1.047, p< p< p< p< , p< , p< , p< , p< There is a gradient for decreasing ORs of mortality, hospital admissions, and ED visits with increasing distance from the hog CAFO. The most pronounced changes (i.e., decrease) in ORs were observed between the distances of 2 km and 5 km from the CAFO.

23 Increase in deaths from breast cancer Residents of zip codes with hog CAFOs: Mortality, OR=1.054, p= ED visits, OR=1.306, p< A greater increase in deaths from breast cancer in residents of zip codes with even more hogs (>215 hogs/km 2) : Mortality, OR=1.115, p= Hospital admissions, OR=1.152, p< ED visits, OR=1.276, p< Residents of zip codes with coal ash ponds: Hospital admissions, OR=1.298, p< ED visits, OR=1.474, p<0.05.

24 Increase in deaths from cervical cancer Residents of zip codes with hog CAFOs: mortality, OR=1.199 (p<0.05). A greater increase in deaths from cervical cancer in residents of zip codes with even more hogs (>215 hogs/km 2) : mortality, OR=1.542, p<0.005, Hospital admissions, OR=1.245, p<0.005, ED visits, OR=1.32, p<0.005.

25 Increase in deaths from prostate cancer Prostate cancer age-adjusted mortality in NC vs. US, age 65+, all races, (CDC WONDER). Residents of zip codes with hog CAFOs: mortality, OR=1.073, p<0.05. Mortality at age 65+, OR=1.103, p<0.01. Hospital admissions OR=0.96, p< US A greater increase in deaths from prostate cancer in residents of zip codes with even more hogs >215 hogs/km 2 : Mortality OR=1.145, p= Hospital admissions OR=0.948, p= ED visits OR=1.25, p< NC

26 Conclusions Although causality is not proven, these data suggest an intervention is warrented. Non uniform distribution of environmental toxins due to wind, elevation, water flow may impact exposures. Cancer is relatively rate, and onset may take decades. Other health effects, perhaps more common, and more acute, may better reflect effects of the environment on health. Larger data sets, such as national or international data may be needed for more definitive cancer studies